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Genetic research in the blood bank: acceptability to Northern California donors
Associated data.
Blood banks have large altruistic donor populations and existing infrastructure that make them attractive sites for genetic epidemiologic research, but donors’ willingness to participate and the impact on blood donation are unknown.
STUDY DESIGN AND METHODS
A total of 2162 blood donors in Northern California responded to a cross-sectional questionnaire in August and September 2007. Participants were asked their likelihood of participation and future blood donation under three different scenarios: identity-linked genetic research, identity-unlinked genetic research, and genetic testing as a service.
The majority of blood donors indicated that they would be likely or very likely to participate in identity-linked genetic research (67%) and in identity-unlinked genetic research (54%). While older donors and more frequent donors were more likely to participate in identity-linked research, younger, Caucasian, more educated, and more frequent donors were more likely to participate in identity-unlinked research. Less than 10% of donors indicated they would be less likely to donate blood in the future if genetic research was conducted at blood banks. More than 75% of donors would be interested in genetic testing as an optional service at the blood bank, but more than 20% of donors would be less likely to donate if such a service was offered.
Overall, we found that the majority of blood donors would be likely to participate in genetic research and that less than 10% would be less inclined to donate if such research was conducted by blood banks.
Blood banks may be uniquely positioned to conduct large genetic epidemiologic studies. They have a broad donor base, collect blood samples frequently, test them for infectious agents using nucleic acid technology, and routinely collect demographic (phenotype) information into large databases. 1 Large repositories of banked specimens from blood donors exist. 2 At the same time, blood donor return rates are of increasing concern to blood banks and the potential adverse impact of genetic studies on these rates are unknown. 3 , 4
Researchers have examined participation rates in genetic studies in other US populations and have found that the acceptability of allowing future unlimited research on stored specimens varies widely. In a recent review, Sterling and coworkers 5 found that consent rates for genetic studies among individuals who had previously participated in health research ranged from 21% to 85%. Consent rates varied by demographic characteristics such as sex and race and/or ethnicity. The REDS-II study recently reported that 91% of donors who consented for a study of HLA antibodies were also willing to have their blood samples stored in a biorepository for future research use to “improve our understanding of transfusion biology and transfusion safety.” 6 Odds of repository participation were lower for subjects who were African American or Hispanic, were 35 to 44 years old, or had not completed high school and were lowest at one geographic location, regardless of other variables.
But to our knowledge, there have been no studies specifically examining US blood donor opinions on participation in genetic research or testing and intention of ongoing donation if such research were undertaken by the blood center. We therefore conducted a survey among blood donors with three goals: to assess blood donor interest in participating in genetic studies through blood banks, to measure the potential impact of genetic studies on future blood donations, and to estimate donor interest in genetic testing offered by blood banks as an optional service.
MATERIALS AND METHODS
Study design and population.
This was a cross-sectional, anonymous survey of blood donors. In August and September 2007, we administered a brief anonymous survey to blood donors at eight fixed collection sites and four mobile drives at a single blood center in the San Francisco Bay Area. All whole blood and apheresis donors passing donor eligibility criteria were eligible to participate. They were given a questionnaire at the time of registration at the collection site and asked to return it anonymously into a box at the postdonation canteen area. Individuals unable to read or understand English or Spanish were not included in the study. The Committee on Human Research at the University of California, San Francisco, approved the study protocol.
In the questionnaire (see Appendix S1 , available as supporting information in the online version of this paper), participants were asked how likely they would be to participate in three different scenarios at the blood bank: genetic research where donor identities would be linked to their samples, genetic research where donor identities would not be linked to their samples, and genetic testing as a service. Donor intent to participate was assessed by 5-point Likert scales ranging from “very likely” to “very unlikely.” In addition, we asked participants whether they would be more or less likely to donate in the future if they were asked to participate in each of the above scenarios at the blood bank. We assessed likelihood of future donation by a 5-point Likert scale ranging from “much more likely” to “much less likely.” In addition, we collected information on participant demographics as well as information on which diseases participants would consider for genetic testing and how much, if anything, they would pay for the service. Before administration of the survey, we conducted pilot testing with 10 donors using cognitive testing techniques. 7 Pilot participants were asked to think aloud as they completed each item in the self-administered questionnaire. At the completion of each item, participants were asked a series of scripted and unscripted probes to determine if they understood the questions and interpreted the items as was intended by the research team. The questionnaire was revised based on pilot participant responses.
Statistical analysis
We calculated frequencies for questions on potential participation in genetic studies and/or testing and likelihood of future blood donation, as well as for demographic information among all 2162 participants. To determine whether likeliness to participate in future research and to donate in the future differed by demographic characteristics, we restricted our analysis to the 1992 donors who provided information on their age, sex, education, race and/or ethnicity, and donation frequency. We constructed separate multivariate logistic regression models for identity-linked genetic research, identity-unlinked genetic research, and genetic testing to calculate multivariate adjusted odds ratios (ORs). Demographic variables were thought to be potential confounders for each other a priori and therefore were included in all multivariate models. All statistical analyses were conducted using computer software (SAS, Version 9.1, SAS Institute, Cary, NC).
A total of 2162 allogeneic whole blood and apheresis donors participated; their characteristics are displayed in Table 1 . Approximately half of participating donors were age 50 or older, and almost 70% were 40 years of age or older. One-fourth of participants were non-Caucasian and participants were evenly split between men and women. The vast majority of participants (90%) had attended some college and approximately 60% had a bachelor’s degree or higher. Only 5% of participants were first-time donors and more than 60% indicated that they had donated six or more times in the past 5 years. Compared to all donors at the blood center in 2007, participants were of similar sex, but older, more likely to be of Caucasian race and/or ethnicity and higher educational attainment, and less likely to be first-time donors.
Participant characteristics *
In the scenario with identity-linked genetic research, 67% of donors indicated that they were very likely or likely to participate ( Fig. 1 ). In a multivariate model, younger donors aged 20 to 49 were less inclined to participate in identity-linked research compared to donors aged 60 or older (OR, 0.45–0.66; p < 0.05; Table 2 ). In addition, participants who were first-time donors were less inclined to participate than donors who had donated more than 20 times in the past 5 years (OR, 0.54; 95% confidence interval [CI], 0.33–0.86). Only 8% of participants believed that they would be less likely or much less likely to donate blood in the future if they were asked to participate in identity-linked research when they donated blood ( Fig. 2 ). In the multivariate model, donors age 60 or older, those who had donated blood three times or less in the past 5 years, non-Caucasian donors, and donors with less than a bachelor’s degree indicated that they were less likely to donate blood in the future if they were asked to participate in identity-linked research at the blood bank ( Table 3 ).
Likelihood of blood donor participation in genetic research.
Likelihood of donating blood in the future.
Multivariate logistic regression: likely to participate in genetic research and/or testing *
Multivariate logistic regression: less likely to donate in future if asked to participate in genetic research and/or testing at the blood bank *
In the scenario where donor identities would not be linked to their samples, 54% of participants indicated that they were likely or very likely to participate ( Fig. 1 ). In a multivariate model, older donors, non-Caucasian donors, donors with less than a graduate school education, and participants who had donated five times or less in the past 5 years were less inclined to participate in identity-unlinked research ( Table 2 ). Nine percent of participants believed that they would be less likely or much less likely to donate blood in the future if asked to participate in identity-unlinked research at the blood bank ( Fig. 2 ). In a multivariate model, donors aged 60 or older, non-Caucasian donors, and donors with less than a bachelor’s degree were less likely to donate blood in the future if asked to participate in identity-unlinked research ( Table 3 ).
Finally, we asked donors whether or not they would be interested in being tested if the blood bank offered genetic testing as an optional service. Approximately three-fourths of participants indicated that they would be interested in genetic testing, 9% indicated that they would not be interested, and 15% stated that they did not know if they would want to be tested. In a multivariate model, high school–educated donors were less interested in genetic testing as a service compared to donors who had attended graduate school (OR, 0.53; 95% CI, 0.35–0.83; Table 2 ). Among donors who were interested in genetic testing or did not know if they would be interested, one-quarter indicated that they would not pay for genetic testing at the blood bank. Thirty-one percent were willing to pay up to $49 for genetic testing, 12% would pay between $50 and $99, whereas only 9% were willing to pay $100 or more. Almost one-quarter of these donors did not know how much they would be willing to pay for genetic testing. Among those who stated they would be interested in genetic testing or were undecided, 90% stated that they were interested in being tested for heart disease, 83% would be interested in being tested for colon cancer, and 82% would be interested in being tested for diabetes. More than 60% of those participants indicated that they would be interested in being tested for breast and ovarian cancer and prostate cancer. Twenty-three percent of all participants indicated that they would be less likely or much less likely to donate blood in the future if genetic testing was offered as an optional service at the blood bank ( Fig. 2 ). This was a higher proportion of participants than in identity-linked and identity-unlinked research. Non-Caucasian donors, donors with less than a graduate education, and donors who had donated five times or less in the past 5 years were less likely to donate blood in the future if genetic testing was offered as an optional service ( Table 3 ).
Participants were able to provide narrative comments at the end of the questionnaire, and these provide some additional insights. Both donors who stated that they would be likely to participate in identity-linked studies and those who stated that they would be unlikely to participate in such studies expressed concerns about the potential loss of privacy. Some donors were concerned that insurance companies would become aware of their genetic information. However, several donors commented that they would prefer to know individual results of genetic research, which could not occur in the identity-unlinked scenario. Consistent with the altruistic nature of blood donors, several donors stated they would participate in either scenario because they believed that health research is very important and others could benefit from their participation.
The main finding of this study was that the majority of blood donors would be likely to participate in genetic studies and that less than 10% of donors would be less inclined to donate in the future if genetic studies were conducted in blood banks. Contrary to expectations, more donors indicated that they would be likely to participate in identity-linked research compared to identity-unlinked research. Finally, there was interest in the provision of genetic testing as a service at the blood center, although this scenario was accompanied by a higher potential for discouraging future donation.
Our main finding that the majority of blood donors expressed a willingness to participate in genetic research is consistent with the altruistic nature of blood donation and with some, but not all, of the findings from other populations. Among individuals who had previously participated in health research, actual consent rates for genetic studies have ranged from 21% to 85%. 5 Researchers recently conducted an online survey of US adults, asking about their potential participation in a large cohort study examining genetic, environmental, and lifestyle factors. Sixty percent of participants indicated that they would participate in such a study. 8
We observed some demographic and donation status differences in willingness to participate in genetic research. Older donors were more likely than younger donors to participate in identity-linked research; however, younger donors were more likely to participate in identity-unlinked research. In general, more frequent donors would be more likely to participate in future genetic studies. We suspect that more frequent donors have established a greater degree of trust with the blood bank that counterbalances concerns about confidentiality, resulting in a greater willingness to participate in even identity-linked genetic research.
While a previous study examining consent rates for genetic research reported lower consent rates among women, 9 we did not detect any differences by sex. Non-Caucasian donors were less likely than Caucasian donors to indicate they would participate in genetic studies, although the difference was only significant for identity-unlinked research. In a recent review, Sterling and coworkers 5 noted significantly lower participation rates among African Americans compared to Caucasians in several studies. In a National Health and Nutrition Examination Survey (NHANES) report, both females and non-Hispanic African Americans were less likely to consent to having their biologic samples stored in a national repository. 9 In an NIH clinical center study, African Americans were less likely to permit future research, although 75% still authorized unlimited future research with their samples. 10 On the other hand, Wendler and colleagues 11 reviewed enrollment data from 20 health research studies and found little overall difference in participation rates between African Americans or Hispanics compared to non-Hispanic Caucasians. However, none of the studies of medical or surgical intervention reviewed by Wendler and colleagues included a primary genetic research question.
The finding of a greater acceptability of identity-linked versus unlinked research was unanticipated. We predicted that the better protection of confidentiality in the identity-unlinked scenario would be more attractive to donors. A possible explanation is that donors are interested in receiving the individual results of genetic research. This desire may temper privacy concerns that participants noted. Interestingly, in the survey of US adults about participation in a cohort study of genetic, environmental, and lifestyle factors, 75% of participants indicated they would be less inclined to participate if they did not receive research results. 8 Others have noted greater than anticipated public interest in more public sharing of genetic information similar to the concept of the Personal Genome Project. 12
The survey found that less than 10% of donors would be discouraged from donating if their blood center participated in genetic research and that more than 10% would be more likely to donate in the future. These results are encouraging, since donor loss is frequently mentioned by blood center personnel as a concern when genetic research is proposed. However, a donor loss of 8% to 9% without a concomitant increase in blood donation due to genetic research could be detrimental to blood banks. Under both identity-linked and -unlinked scenarios, donors aged 60 or older, non-Caucasian donors, and donors with less than a bachelor’s degree were more likely to be among this small group. We did not ask why donors would be less likely to donate in the future; however, we suspect that older donors view genetic studies as distracting from the blood center’s primary mission. In addition, comments on the questionnaire indicated that a few donors were unsure if participation in the study would be optional for blood donors, potentially contributing to the observed differences by level of education. In a previous study, we found that non-Caucasian donors had 30% to 40% lower odds of donating blood again within 1 year compared to Caucasian donors. 13 This observation was also evident when we examined return after donor deferral regardless of first-time or repeat donor status. 14 The racial disparity we observed in this study may be indicative of the larger pattern of lower repeat donation rates among non-Caucasian donors. Previously, we found that non-Caucasian donors were more likely than Caucasian donors to cite poor staff skills and bad treatment as factors influencing their decision not to donate blood in the future. 15 Another study found that the race of the research physician, knowledge of the Tuskegee study, and belief that minorities bore most of the risks in medical research influenced African American subjects’ willingness to participate in medical research. 16 These findings will have relevance to the design of future genetic studies in the blood donor setting, particularly in the design of educational and consent materials as well as staff training.
More than 70% of donors indicated that they would be interested in genetic testing as an optional service, with more than 80% of interested or undecided donors indicating that they would be interested in being tested for heart disease, colon cancer, and diabetes. However, more than 20% of participants indicated they would be less likely or much less likely to donate blood in the future if genetic testing was offered (as a service as opposed to research). During pilot test interviews, some donors indicated that genetic testing would make the donation process more complicated and introduce new processes. It is also possible that some participants did not understand that genetic testing would be optional rather than required for blood donation. Pilot test interviews indicated that even if the disease was not relevant to their personal health, some participants would be interested in being tested for genetic traits that may be passed to their children. Therefore, we specified that genetic testing could be for diseases the participant may develop or for diseases that the participant may pass on to their children. As a result, some men responded they would be interested in genetic testing for breast and ovarian cancer and some women indicated they would be interested in testing for prostate cancer.
There are limitations to our study. First, we used a convenience sample of predominantly repeat donors at one Northern California center who were willing to participate. Due to response bias, their opinions may not be representative of other blood donors at this center nor of all US blood donors. Questions were complex and required detailed descriptions of genetic studies, genetic testing, and linked or unlinked samples, so it is possible that some individuals, particularly those with less education, did not comprehend the scenarios presented. However, we conducted detailed pilot testing before our study to revise the instrument and maximize comprehension of the three scenarios. In addition, participants were highly educated, with more than 90% indicating that they at least had some college education. Another limitation is that donors were asked to indicate what they would do in a hypothetical scenario. However, we have previously found that donor intention to return is predictive of actual return. 15
In conclusion, our study reveals that factors about the research study design, such as whether samples are linked to donor information, as well as donor demographics and donation status, will impact donor consent rates in genetic studies. The finding that the majority of donors would be interested in participating in genetic studies is encouraging with regard to the feasibility of conducting genetic research in the blood bank setting. However, donor loss due to genetic research in the blood bank remains a potential concern. Therefore, we suggest that if genetic research is implemented in blood banks, studies should be implemented slowly and actual participation and refusal rates as well as subsequent donation trends should be monitored.
Supplementary Material
Acknowledgments.
The authors wish to thank the staff at Blood Centers of the Pacific for assistance in questionnaire administration. Funded in part by NIH midcareer award K24-HL-75036 to Dr Murphy and by NIH training grant T32-CA-09001 to the Harvard School of Public Health.
CONFLICT OF INTEREST
No conflict of interests to disclose.
SUPPORTING INFORMATION
Additional Supporting Information may be found in the online version of this article:
Appendix S1 . Your opinions about genetic research?
Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
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Original research article, assessment of beliefs, behaviors, and opinions about blood donation in telangana, india—a cross sectional community-based study.
- 1 Volunteering Researcher in the Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- 2 Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- 3 Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Al-Madinah, Saudi Arabia
- 4 Pharmaceutical Care Division, King Saud Medical City, Riyadh, Saudi Arabia
Background and Objectives: Blood is an essential body fluid primarily required for regulating the body's systems and maintaining homeostasis. In developed and developing countries, concern about the demand and supply for blood is increasing. The current study aims to assess the beliefs, behaviors, and opinions of the public toward blood donation.
Methods: This was a cross-sectional study in which a self-created questionnaire with 17-items was used for data collection. The self-administered questionnaire was disseminated between November 2019 and January 2020 through social media (WhatsApp© and Facebook©). Data was analyzed using SPSS program version 26.
Results: A total of 356 questionnaires were completed with a response rate of 89%. The majority of participants were male 253 (71.1%), 336 (94.4%) considered blood donation important, 350 (98.3%) believed that blood donation saves lives, and 254 (71.3%) agreed to receive blood from voluntary donors. One-hundred sixty-seven (49.4%) were willing to donate blood voluntarily. The barriers to blood donation were fear of needles 86 (24.2%), fear of contracting a chronic disease 84 (23.6%), and lack of time 40 (11.2%). One day off (91.9%) and receiving a token 73.6% were common motivational factors for blood donation. Overall, 57% of the participants had favorable attitudes toward blood donation and 41.9% were knowledgeable. Favorable attitudes were significantly associated with being married ( P = 0.018) and having university level of education ( P = 0.005). Younger participants (18–29 years) had a statistically significant better knowledge than older participants (≥30 years).
Conclusion: The respondents displayed positive beliefs, opinions, and motivation toward blood donation. Additionally, most of them considered blood donation an important act and a national duty of every individual and are willing to donate in the future.
Blood is an essential body fluid primarily required for regulating the body's systems and maintaining homeostasis ( 1 ). However, the demand for a safe supply of blood is increasing on a daily basis internationally, and India is no exemption ( 2 , 3 ). Although previous studies reported that blood transfusions save millions of lives each year, the quality and safety of blood remain a serious concern, particularly in developing countries ( 2 – 4 ). Indeed, concern about the demand and supply for blood is increasing in developed and developing countries ( 5 , 6 ). However, out of 195 nations, the blood supply of 119 (61%) nations were found inadequate for healthcare needs ( 5 , 7 ). Interestingly, early findings indicated that India has the world's largest shortage of blood supply. Conversely, the prevalence of blood borne diseases in India is on the rise as blood is essential for the treatment of various diseases (e.g., sickle cell anemia), bleeding disorders (e.g., hemophilia), and cancer. Evidence indicates that India is home to major surgical procedures, such as ~230,000,000 operations, 331,000,000 cancer procedures, and 10,000,000 pregnancy-related operations, every year. Such procedures require a large amount of blood ( 7 , 8 ).
Blood donation is a pillar of modern medicine and saves millions of lives every year ( 7 , 8 ). Nevertheless, many hospitalized patients in low- and middle-income countries lack access to safe and free supply of blood in a timely manner. Previous studies estimated that out of the demand for 303 million units of blood worldwide in 2017, only ~272 million units were supplied. In the 119 countries with insufficient blood supply, the shortfall reached 100 million units ( 7 , 8 ).
Moreover, previous studies conducted in India evaluated the attitudes and motivational factors of the public toward blood donation and reported false beliefs among individuals regarding the effects of blood donation, such as infertility, loss of strength, early aging, and anemia ( 2 , 6 ). Similarly, studies from developed countries like America and Japan also reported similar barriers toward blood donation ( 9 , 10 ). However, another study by Shah et al. at a blood bank in a tertiary hospital in Mumbai reported laziness and fear of infection as the major factors for blood donation hesitation ( 11 ). In developed countries, published reports demonstrated that lack of access to blood donation centers was the main factor for blood donation hesitation ( 12 – 16 ). Additionally, barriers are different between genders. Failing to meet the eligibility requirements has been reported commonly by females while most males reported that they were never asked to donate blood ( 17 , 18 ).
According to estimates from the Central Drugs Standard Control Organization (CDSCO), the National Regulatory Authority (NRA) of India, Telangana has 151 blood banks comprised of both private and governmental blood banks, with Hyderabad having the most. Healthy adults between the ages of 18 and 75 who fulfill the donor eligibility requirements can donate blood ( 19 – 21 ). All blood banks are easily accessible to the general public, whether by walk-ins or by appointment ( 20 , 21 ). Additionally, the city has mobile blood banks making blood donation convenient for all citizens and aims to save lives by connecting donors to blood banks ( 22 ).
A dearth of literature exists in this regard, particularly in Telangana, a state in India. Furthermore, international studies on blood donation and its acceptance among the public are limited and evaluating public attitudes and motivations toward blood donation using different methods is required. In addition, the availability of a safe blood supply in healthcare centers is another challenge. Research focused on the attitudes, opinions, and motivations toward blood donation can provide an overall picture of the state of blood supply to healthcare centers not only in India but also across the world. Therefore, the aim of this study was to assess the beliefs, behaviors, and opinions of the general public toward blood donation in Hyderabad, the capital city of Telangana, India.
Materials and Methods
Participants and design.
A cross-sectional web-based community study was conducted among adults from November 2019 and January 2020 using a structured, self-administered questionnaire. The study included individuals from Hyderabad city, Telangana state, India who aged more than 18 years, who can read and understand the English language.
Sample Size Determination
The sample size ( N ) was based on the previous number of blood donors in India (89.5%) ( 2 ) and calculated as follows:
where N is the minimum sample size; z denotes the level of confidence according to the normal standard distribution that corresponds to the 95% confidence interval ( z = 1.96); p stands for the prevalence rate of blood donors (0.895); q = (1 – p ); and d pertains to the desired degree of accuracy or tolerated margin of error (5%; 0.05). Substituting these values into the equation, the following equation is derived:
Therefore, N = 356.
Questionnaire Design
A structured, self-administered questionnaire in the English language was prepared through an extensive literature review ( 12 – 15 ). The questionnaire was composed of the following demographics: age, gender, level of education, and employment status. The second part was intended to collect data on the attitudes, opinions, and motivations toward blood donation using 17 items with binary answers and multiple-choice questions. The questionnaire was assessed for the level of comprehensiveness, clarity, avoidance of ambiguity, and content validity by two senior researchers and one clinical pharmacy professor who were experts in the field. A pilot study was conducted on 10 randomly selected individuals who did not mention any suggestions or corrections related to the wording, length, and format of the questionnaire. The pilot results were excluded from the main findings. The reliability of the final questionnaire was assessed using internal consistency. The Cronbach's alpha value was 0.71, indicating an acceptable reliability of each item.
Data Collection
The final questionnaire Google Forms ® link was sent to the participants through WhatsApp© and Facebook© prefaced by the eligibility requirements of participation such as consent and age restrictions. The snowball technique was used to collect data, that is, one participant was requested to refer other individuals to participate. An invitation link containing the questionnaire was sent randomly to the participants without previous measures. First, the research team targeted friends and family members, explained the objective of the study through phone calls and messages, and invited them to fill and forward the questionnaires to family, friends, acquaintances, and any other eligible individual currently living in Telangana. Complete responses to the survey were considered written informed consent as the survey included a statement on consent. To facilitate completion, the respondents were sent frequent reminders about the importance of their participation and requested to submit the completed questionnaire.
Data Extraction
The submitted questionnaires were checked for accuracy and completeness. Missing or incomplete responses were excluded ( Figure 1 ).
Figure 1 . Flowchart of responses.
Data Analysis
Data were further extracted to exclude bias in sample selection, which was limited to only the central region, and analyzed using Microsoft Excel followed by a descriptive analysis. Categorical data were calculated as frequencies and percentages. The Statistical Package for the Social Sciences version 22.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. A chi-square test was used to identify associations between variables. A difference with a P -value of >0.5 was considered statistically significant.
Participant Demographics
A total of 400 questionnaires were returned, out of which 44 (9%) were incomplete and thus excluded. Therefore, the final number of respondents was 356 for a response rate of 89%. The gender-wise greater proportion of the respondents were male 253 (71.1%), and the majority 291 (81.7%) were aged between 18 and 29 years. Of the 356 respondents, 233 (65.4%) were single, and slightly more than half 186 (52.2%) were unemployed. Most of the study participants, 282 (79.9%), were University graduates. Table 1 provides the demographics of the respondents.
Table 1 . Demographics of the participants ( n = 356).
Attitudes Toward Blood Donation
The majority of respondents 336 (94.4%) recognized the importance of blood donation. Nearly all the participants 350 (98.3%) stated that blood donation can help save lives, whereas 254 (71.3%) agreed to receive blood from voluntary donors. In terms of blood donation being a national duty, 203 (57%) agreed to the statement. However, slightly less than half of the respondents 167 (46.9%) would voluntarily donate blood if needed, whereas 171 (48%) may donate blood to friends and families in the future. Table 2 provides detailed information of the respondents' attitudes.
Table 2 . Attitudes and opinions toward blood donation ( n = 356).
Barriers Toward Blood Donation
Figure 2 describes the fears and misconceptions that prevent individuals from donating blood. Approximately one-fourth of the respondents 86 (24.2%) avoid donation for fear of needles, 101 (29%) reported no specific reasons, whereas 84 (23.6%) reported a fear of contracting chronic diseases. However, only 40 (11.2%) reported lack of time as the main barrier to blood donation ( Figure 2 ).
Figure 2 . Fears and misconceptions preventing donors from donating blood.
Knowledge and Motivational Factors
Approximately 49.7% of the respondents reported that a healthy person may donate once a year, whereas 14 and 11.3% answered twice and thrice a year, respectively. The majority (73.8%) preferred to donate in blood banks, whereas 83.1% of the subjects were not rejected for blood donation in the past year. Regarding motivational factors, the majority (91.9%) agreed that a 1-day leave should be provided as compensation, whereas 73.6 and 25% preferred that a token and money should be given as rewards, respectively. Furthermore, the majority (93%) agreed that blood donation is an important valuable act and reported satisfaction in donating blood as a means of helping friends and family members. Tables 3 , 4 provide detailed descriptions of the responses.
Table 3 . Knowledge and motivations about blood donation ( n = 356).
Table 4 . Factors motivating blood donation.
Married individuals had a statistically significant favorable attitude compared to single participants ( P = 0.018). Participants with a university level of education had statistically significant favorable attitudes compared to those with high school education ( P = 0.005) ( Table 5 ).
Table 5 . Cross-tabulation between demographic characteristics and attitudes categories.
Younger participants (18–29 years) had a statistically significant better knowledge than older participants (≥30 years). A statistically significant differences in knowledge categories were also reported among marital status ( P = 0.003), educational status ( P = 0.001) and employment status ( P < 0.001) ( Table 6 ).
Table 6 . Cross-tabulation between demographic characteristics and knowledge categories.
The respondents indicated positive beliefs, behaviors, and opinions toward blood donation. Furthermore, the majority agreed that blood donation is an important act and helps save lives. Additionally, nearly all respondents indicated willingness to donate if asked, and ~47% would donate blood as volunteers. The current results are better than those of previous studies conducted in the capital of India, where the authors reported that 69% of the respondents displayed positive attitudes toward blood donation and considered blood donation as the duty of every individual to the community ( 23 ). Joshi and Meakin conducted a study among Indian non-donors living in England and reported a variety of attitudes, but generally positive ones ( 4 ). Olaiya surveyed citizens in Nigeria, a developing country, and reported that 92.9% of the participants donated blood and demonstrated positive attitudes toward blood donation ( 24 ). However, Majdabadi et al. reported moderate attitudes among medical students in Tehran ( 6 ). Additionally, other previous studies proposed that increased awareness and motivational factors were associated with good knowledge and attitudes toward blood donation ( 6 , 12 , 24 – 26 ).
Previously published studies indicated an association between good knowledge, attitudes, and opinions toward blood donation and the availability and safe supply of blood in transfusion centers ( 12 – 15 ). This objective can be achieved further through increased awareness about blood donation and its importance and in-depth research on the motivational factors that encourage donors to donate. The present study found that one's fear of needles, fear of contracting chronic diseases, and lack of time were potential barriers that limit blood donation among the respondents. However, Shah et al. argued that fear of infection (21%), fear of needles (15%), and laziness were the major factors (46%) for the blood donation hesitancy ( 11 ). Similarly, a recent population-based study by Alfouzan et al. pointed to lack of time (45%) and access to blood donation centers (41.3%) ( 12 ). Karim et al. reported fear among Bangladeshi population ( 26 ). Interestingly, Dubey et al. reported that respondents were not requested to donate blood, which was considered the main potential barrier among respondents ( 2 ). Moreover, Abdurrahman and Saleh identified the side effects of receiving blood or blood components, health problems, fear of blood, medical errors, time restraints, lack of required conditions for donation, and fear of acquiring infections (e.g., HIV) as barriers among donors ( 13 ). The different types of fear among subjects, as reported by the present and previous studies, should be addressed by highlighting the importance of blood donation through programs that promote awareness, whereas misconceptions regarding infections due to blood donation should be elucidated through various educational programs about donation.
The current study demonstrated that the respondents held positive attitudes, opinions, and motivations toward blood donation in India. The findings were consistent with those of previous studies conducted in developed and developing countries and found overall positive and attitudes and perceptions toward blood donation ( 2 , 11 – 13 ). In the current study, however, the majority of participants were willing to donate blood if asked and nearly half would donate as volunteers. These findings supported Dubey et al., who stated that most potential donors (57.25%) would donate only if required for family or friends with self-sacrifice as a lesser priority (16%) ( 2 ). However, Abdurrahman and Saleh reported that 61.2% of participants revealed that their main goal for donation is helping others and saving lives, even individuals they do not know ( 13 ). Additionally, Dubey et al. found that 13.5% of the respondents were non-donors, where 7.75% agreed to donate to gain awareness about their HIV status ( 2 ). Lastly, non-monetary incentives, if carefully targeted, can attract and retain donors ( 2 , 15 ).
In the current study, the majority of respondents suggested a token, leave from work, and cash money as motivational incentives for donating blood. The results were comparable to those of Alfouzan et al. who reported 1 day off (81.4%), tokens (31.5%), and money (18.9%) as motivating factors ( 12 ). Similarly, Baseer et al. surveyed university students and identified that saving lives (98.4%), serving humanity (96.9%), and helping family and friends (95.3%) were the main motivations for donation ( 14 ). Karim et al. reported that family background, physical status, urgency for family, awareness/knowledge, and maturity level were the factors that increased participant willingness to donate ( 26 ). Irrespective of gender and age, individuals hold personal beliefs and misconceptions about donating and accepting blood anonymously ( 2 , 13 ). However, the respondents of the present study agreed with importing blood from abroad. Additionally, previous studies proposed that socio-demographic, organizational, physiological, and psychological factors may influence the decision of individuals to donate and accept blood ( 13 – 16 ). Many studies reported that blood donation is a religious duty, whereas the current results revealed that blood donation is a national duty ( 13 – 16 ). An encouraging fact observed in the study is that individuals are motivated to donate blood.
In this study being younger, educated, married, and employed were shown to have superior knowledge, whereas married individuals and those with higher education had more favorable attitudes scores. Melku et al. revealed similar findings in Ethiopia, with younger people being found to have more knowledge ( 27 ). Similarly, according to Javaeed et al., being a female gender was found to have a high level of understanding about blood donation ( 28 ). In Bangladesh, Karim et al. found that a parent's education was substantially related to the study participants' blood donation behaviors ( 26 ). This data revealed that the participants' education and age were important determinants in their blood donation decisions.
As such, creating awareness in the community and shedding light on the misconceptions about blood donation can aid healthcare facilities and the public in ensuring the availability of blood when needed. Such outcomes demand the need for additional educational and awareness programs specific to blood donation in Asian communities. In addition, this study proposes that increased knowledge about blood donation through education and awareness campaigns may encourage and motivate the general community and subsequently establish a sufficient supply of viable blood based on voluntarism, which is essential to the healthcare setting.
This study has strengths that should be mentioned. It is one of the first studies to be conducted in Telangana's capital, Hyderabad, which has the most blood donation centers. Secondly, it explored the motivations, perceptions, barriers, and possible strategies to mitigate blood donation hesitancy in one of the world's largest developing countries.
This study has some limitations. First, the study is limited to Hyderabad and included a small sample size; therefore, the findings are not generalizable to the entire state of Telangana. Second, the findings are reliant on the completion of the questionnaire, which may generate false answers and introduce the possibility of bias. Additionally, the study did not assess a full scope of motivational factors for blood donation (such as religion, socioeconomic status), also, the study did not collect past experiences with blood donation or transfusion, as participants who previously donated or received blood may have different attitude and knowledge compared to naïve donors. Lastly, most of the participants are young, and college educated, hence extrapolation to older generation and people with less than university education is limited. Given these limitations, the study suggests that future research should employ a larger sample size from various regions throughout India and reaching wider socioeconomic classes with a greater focus on the opinions, attitudes, and motivations as well as barriers toward blood donation. Future questionnaires should include additional motivational factors for donation and perceptions from historical donors.
The findings provide insight into the beliefs, behaviors, opinions, and motivations that are likely to encourage blood donation in Hyderabad. Importantly, the findings represent positive attitudes and motivation toward blood donation, which can provide reference for healthcare systems and blood banks in improving their supply and for supporting the development of programs that aim to ensure a sufficient supply of viable blood in a timely manner. Therefore, education programs that promote motivation and ensure a safe and healthy supply of blood should be advocated at both the national and global levels.
Data Availability Statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics Statement
Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.
Author Contributions
SW: conceptualization, data curation, formal analysis, and visualization. SS: writing—original draft preparation and review and editing. IS: funding acquisition and writing—review and editing. MM: formal analysis and writing—review and editing. GB and MA: writing—review and editing. All authors have read and agreed to the published version of the manuscript.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's Note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Acknowledgments
The authors extend their appreciation to the Deanship of Scientific Research at King Saud University for funding the work through the research group project No. RG-1441- 367. In addition, the authors thank the Deanship of Scientific Research and RSSU at King Saud University for their technical support.
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Keywords: attitudes, motivation, blood donation, Indian adults, fear for needle
Citation: Samreen S, Sales I, Bawazeer G, Wajid S, Mahmoud MA and Aljohani MA (2021) Assessment of Beliefs, Behaviors, and Opinions About Blood Donation in Telangana, India—A Cross Sectional Community-Based Study. Front. Public Health 9:785568. doi: 10.3389/fpubh.2021.785568
Received: 29 September 2021; Accepted: 15 November 2021; Published: 09 December 2021.
Reviewed by:
Copyright © 2021 Samreen, Sales, Bawazeer, Wajid, Mahmoud and Aljohani. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Syed Wajid, wali@ksu.edu.sa
This article is part of the Research Topic
Public Health Promotion and Medical Education Reform
- Research note
- Open Access
- Published: 06 November 2019
Blood donors’ knowledge and attitude towards blood donation at North Gondar district blood bank, Northwest Ethiopia: a cross-sectional study
- Bamlaku Enawgaw ORCID: orcid.org/0000-0002-3828-5318 1 na1 ,
- Aregawi Yalew 1 &
- Elias Shiferaw 1 na1
BMC Research Notes volume 12 , Article number: 729 ( 2019 ) Cite this article
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Blood transfusion saves millions of lives. But, the need and the actual number of donations are not balanced in Ethiopia. The actual reason is not clearly assessed; however, level of knowledge and attitude may be the main contributing factors. Thus, the current study aimed to assess blood donors’ knowledge and attitude towards blood donation at North Gondar district blood bank.
Of 401 blood donors, 142 (35.4%) and 379 (94.5%) were had adequate knowledge and positive attitude towards blood donation, respectively. About 343 (85.5%) of study participants had no previous experience of blood donation. Perceptions of fear of pain, medically unfitness to donate and lack of information on when, where and how to donate blood were mentioned as a reason for not donating blood. Educational status and residence were significantly associated with knowledge of blood donors. On the other hand, participants with secondary and higher education were more likely to have good attitude towards blood donation. Thus, blood banks should design strategies for health education about blood donation and transfusion.
Introduction
Blood donation is remained the major source of blood and blood components worldwide. Even though extensive promising research have come up, a true substitute for blood and blood components is not available [ 1 ]. Donated blood is an essential component in the management of many diseases. It is the main lifesaving for an individual with loss of large volumes of blood from accidents, hemorrhages or surgery [ 2 ].
The source for blood to be transfused relies mainly on voluntary non-remunerated blood donors [ 3 ]. Even though over a million of blood units are collected every year, many more millions still need to be collected to meet the global demand, ensure the sufficient and timely provision of blood [ 4 ]. However, the demand and supply are not being balanced; the demand is escalating. This is the reason why in Sub-Saharan Africa replacement and paid donors are common in contrary to voluntary and non-remunerated donors [ 5 ].
Evidences showed that the annual global blood collection is 112.5 million units of blood. Over half of these units of blood are collected in developed countries. The blood donation rate per 1000 people in high income countries is more than fivefold compered to low income countries (33.1 vs 4.6 donations). Voluntary blood donors cover over 90% of donations in developed countries while they account below 50% in developing countries [ 6 ].
Ethiopia is a country with high maternal mortality (676 per 100,000) and high motor accident and with a large nonimmune population for malaria [ 7 ]. There is insufficiency and in-equitability in access to blood. The average annual national requirement for blood in Ethiopia is 100,000 units per year, but only 43% is collected [ 8 ]. From WHO African countries, Ethiopia has the least number of voluntary blood donors (VBD) with 22% which is extremely very low [ 9 ].
The availability and safety of blood still remain inadequate to meet the increased demand of blood and blood components particularly in Sub-Saharan Africa like Ethiopia [ 5 , 10 ]. As a result, these countries try to compensate their blood demand from family replacement or paid donors. But in this type of donors, higher rates of transfusion-transmitted infections have been documented [ 6 ]. It is explained that healthy VBD donate their blood by their own free will without any pressure, whereas family replacement donors donate blood for fear of loos of their relatives without considering their health status [ 11 ].
The actual reason why large proportion of the potentially eligible population do not actively donate blood is not clearly assessed in Ethiopia. The blood donors’ attitude, beliefs, and knowledge may be a factor for not being a blood donor. Thus, the current study was aimed to assess blood donors’ knowledge and attitude towards blood donation at North Gondar blood bank district, Northwest Ethiopia. The findings will be used as a baseline information for the blood banks to plan an effective strategy to increase and maintain safe and adequate blood supply.
Study setting and population
A cross-sectional study was conducted on 401 blood donors at North Gondar blood bank district, Northwest Ethiopia. This blood bank is the only blood bank center located in Gondar for North Gondar, Amhara regional state, at 738 km far from Addis Ababa, capital city of Ethiopia. The blood bank gives serves for the surrounding hospitals in the district.
Sample size determination and sampling technique
To determine the required sample size for study, a single population proportion formula was used as denoted below.
where z α/2 = 1.96 at 95% confidence interval, p = 50% because there is no previous study, d = 5% which is tolerable error between the sample and true population.
Considering 5% non-response rate (384 × 5% = 19), the final sample size becomes 403. The study participants were selected randomly from the blood donors in the blood bank.
Data collection
The study participants were interviewed during blood donation after obtaining written informed consent. We used a structured pretested questionnaire to collect socio-demographic data, knowledge, attitude, previous blood donation history and reasons for not donating blood previously. In addition to pretest, training was given for data collectors about data collection procedures and objectives of the study. Consistency of the collected data was also checked daily.
Knowledge assessment towards blood donation
We used nine questions to assess knowledge of blood donors. For the “correct” and “incorrect” response, “1” and “zero” score were used, respectively. Then the total score was obtained by summing up of the nine knowledge questions score. The scoring ranges from 0 to 9. Those blood donors who answer “five” and more questions correctly from 9 (> 50%) were considered as knowledgeable.
Attitude assessment towards blood donation
In this study, attitude was assessed using eight questions. Similar to knowledge scoring “1” and “zero” were used for favorable and unfavorable attitude, respectively. The total score was calculated up to determine the total attitude score. The score was ranged from 0 to 8. Attitude score of half and more (50%) was considered as favorable attitude.
Data analysis and interpretation
Data were entered with Epi info 3.5.1 and transported to SPSS 20 for analysis. Descriptive results were summarized and presented with tables. The association of the independent variable with the categorical outcome variable was measured by calculating odds ratio with 95% confidence interval using bivariate and multivariate logistic regression. P value < 0.05 was considered as statistically significant.
Sociodemographic characteristics of study participants
In this study a total of 401 (259 male and 142 female) study participants was included. The response rate was 99.5% (401/403). The mean age of study participants was 26.2 ± 8.2 years ranging from 18 to 57 years old. The majority 212 (52.9%) of them was in the age group of 18–23 years. More than half 235 (58.6%) of the donors had been attending higher education. Majority 188 (46.9%) and 281 (70.1%) of the study participants were students and single in marital status, respectively (Table 1 ).
Knowledge of study participants
From the total study participants, 142 (35.4%) had adequate knowledge towards blood donation. The mean knowledge score of the participants was 4.03 ± 1.44. All of the study participants argued that the importance of blood donation is to save life. From the total study participants, 380 (94.8%) of them had information regarding screening of donated blood for infectious disease before transfusion. But only 20 (5.0%) of the study participants knew HIV, hepatitis virus and syphilis are considered as transfusion transmittable infections (Additional file 1 ).
Attitude of the study participants
Nearly all [379 (94.5%)] of the study participants had favorable attitude towards blood donation. The mean attitude score of the participants was 7.48 ± 1.23. Majority 365 (91.0%) of the participants had a plan to donate blood voluntarily in the future and about 360 (89.8%) of the study participants had plan to become a regular blood donor. Majority 373 (93%) of the study participants had a perception of donation is not harmful to donors (Additional file 1 ).
Previous practice of blood donation
Less than one quarter 58 (14.5%) of study participants had previous history of donation and more than half 229 (57.1%) of them were replacement type of donors. Several factors have been mentioned as a reason for not donating blood previously. About 139 (40.5%) of the blood donors mentioned lack of information (when, where and how to donate) as the main reason for not donating blood previously. Fear of pain, perceptions of unfitting to donate and consideration of donation as harmful practice had also been mentioned as a reason for not donating blood previously (Additional file 2 ).
Factor associated with knowledge of blood donors
In multivariate logistic regression analysis educational status, residence, previous donation history and donor type were significantly associated. Study participants who attained higher education (AOR = 2.8, 95% CI 1.35, 6) and those who lived in urban (AOR = 2.5, 95% CI 1.26, 4.81), history of previous donation (AOR = 2.2, 95%CI 1.13, 4.48) and being volunteer blood donors (AOR = 3.1, 95%CI 1.5, 6.56) were more likely to have adequate knowledge. Age, gender, marital status and occupation were not showed a statistically significant association (Table 2 ).
Factor associated with attitude of blood donors
Bivariate logistic regression analysis showed that age, educational status, occupation, residence and marital status were significantly associated with attitude of participants. While in multivariate logistic regression analysis none of them were statistically significant. Variables such as gender, previous donation history and donor type did not fulfil the criteria for logistic regression analysis and were excluded from analysis (Table 3 ).
In this study about one-third of blood donors had adequate knowledge towards blood donation. The result was slightly higher than a study conducted in Jordan which reported that 28.6% of them had adequate knowledge towards blood donation [ 4 ]. The possible reason for this discrepancy might type of blood donors. In our study, the number of replacement type of blood donors was relatively low (229 vs 348). It is strongly believed that volunteer blood donors are more likely to have good knowledge towards blood donation compared to replacement type donors and it is considered as major contributing factor for blood donation. This study showed that 61% of voluntary and 16.2% of replacement blood donors had adequate knowledge.
On the other hand, the level of knowledge in this study was lower than studies from Gondar [ 12 ], Bahir Dar [ 13 ], Wolita Sodo [ 14 , 15 ], Tigray [ 16 ], Birbir Town [ 17 ], Harar [ 18 ], Basrah, Iraq [ 19 ] and India [ 20 ]. The difference may be associated with the type of study subjects included in the studies. The above-mentioned studies include medical and health science students and also health care workers. Thus, it is expected that this group of people have high level of knowledge towards blood donation.
In the current study, all of the participants argued that the importance of blood donation is to save life. But a previous report from Gondar town showed a slight deviation result of 88.3% [ 21 ]. Similarly, it was higher than a study conducted in Democratic Republic of Congo which showed that only 183 (44.1%) of the study participants strongly advocates this idea [ 22 ]. The difference might be due to variation in study subjects (blood donors vs general population in the community).
In this study, participants who attained higher education and lived in urban were more likely to have adequate knowledge towards blood donation. This is supported by studies in Birbir Town [ 17 ] and Harar [ 18 ] in which individuals with higher education has high level of knowledge. Similarly, those donors who were donate blood previously and volunteer donors were had adequate knowledge compared to their counterparts. This is true that if someone had experience, he/she has high level of knowledge. Thus, it is not surprise that if the donors with previous history had adequate knowledge.
Regarding to attitude, nearly all of the respondents had a good attitude towards blood donation. The finding was slightly higher as compared to the previous report from Gondar [ 12 , 21 ], Bahir Dar [ 13 ], Wolita Sodo [ 14 , 15 ], Tigray [ 16 ], Birbir Town [ 17 ], Harar [ 18 ], Basrah, Iraq [ 19 ] and India [ 20 ]. The difference might be due to variation in study method and subjects since the current study was institutional based study conducted among the blood donors.
We tried to assess the association of blood donors’ characteristics with their attitude. Variables such as age, educational status, occupation, residence and marital status were assessed, but none of them showed statistically significant association. Nearly all (94.5%) of the study participants had favorable attitude towards blood donation.
In this study, attitude towards blood donation was high, but the level of knowledge was inadequate. Education, residence, previous blood donation and donor type were statistically associated with adequate knowledge. To increase the level of knowledge towards blood donation, health education to the community is recommended.
Limitations
The findings in this study are from one district and only interview-based data were collected. There was no focus group discussion for further analysis of the knowledge and attitude of the participants.
Availability of data and materials
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.
Abbreviations
Adjusted Odds Ratio
confidence interval
Crude Odds Ratio
hepatitis B virus
hepatitis C virus
voluntary blood donors
World Health Organization
voluntary non-remunerated blood donors
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Acknowledgements
The authors would like to express a great gratitude to staffs of North Gondar District Blood Bank for their contribution during the data collection. The authors are also grateful to thank all the study participants and the University of Gondar for giving this opportunity to conduct this study.
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BE and ES participated in designing the study, supervised the data collection, analyzed, interpret and write up the manuscript. AY involve in proposal development, data collection and entry of data for analysis. BE and ES are the joint first authors of the paper. All authors read and approved the final manuscript.
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Knowledge and attitude questions response of blood donors towards blood donation at North Gondar District Blood Bank, Northwest Ethiopia.
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Blood donation practice of blood donors North Gondar District Blood Bank, Northwest Ethiopia.
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Enawgaw, B., Yalew, A. & Shiferaw, E. Blood donors’ knowledge and attitude towards blood donation at North Gondar district blood bank, Northwest Ethiopia: a cross-sectional study. BMC Res Notes 12 , 729 (2019). https://doi.org/10.1186/s13104-019-4776-0
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Blood scarcity at the blood banks during COVID-19 pandemic and strategies to promote blood donations: current knowledge and futuristic vision
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The course of the coronavirus disease (COVID-19) pandemic has significantly affected the healthcare systems in multiple ways, the programs of control and the management of patients with other infectious diseases as well as with chronic and acute non-communicable diseases, including those conditions requiring blood transfusions. Blood donations have been decreasing over time in multiple countries with their expected consequences. Although the spread of SARS-CoV-2 has not been detected via blood transfusion, the increasing fear and anxiety among communities have led to a substantial decrease in blood donations. Several research groups have raised concerns about the consequences associated with the scarcity of blood. However, it is critical to understand the underlying causes of the sharp decline in blood donations, as well as the consequences. Hence, we discuss the impact of blood scarcity at the blood banks during the COVID-19 pandemic as well as strategies to promote blood donations, given the experience in some countries with this situation.
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Transfusion Medicine and Hemotherapy
Research article.
A Cross-Sectional Study of Blood Donors’ Psychological Characteristics over 8 Weeks
Author affiliations a Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany b MVZ Labor Greifswald GmbH, Greifswald, Germany c Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsmedizin Greifswald, Greifswald, Germany
Max Esefeld, [email protected]
Andreas Greinacher, [email protected]
Keywords: Donor research Effects of blood donation Mood regulation
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Background: Previous studies suggest that blood donation impacts blood donors’ psychological state, with either positive or negative effects, such as feeling more energetic or more exhausted. It has not yet been described how long these effects last. Materials and Methods: This prospective cohort study consisted of a qualitative and a quantitative part: (1) Psychological characteristics which changed after blood donation were identified by structured interviews of regular whole blood donors ( n = 42). Based on this, a questionnaire addressing 7 psychological dimensions was established. (2) The psychological state of 100 blood donors was assessed after blood donation by applying the questionnaire 15–30 min before and during donation, as well as 15–30 min, 6 h, 24 h, 72 h, 1 week, and 8 weeks after donation. The resulting changes were summarized to a score. Furthermore, potential correlations of the score with pre-donation blood pressure, hemoglobin, or body mass index were calculated. Results: Seven items were identified which changed in at least 25% of blood donors (mood, concentration, satisfaction, resilience, spirit of initiative, physical well-being, energy level). In the 100 blood donors, the well-being score increased (positive effects, n = 23), showed minor changes ( n = 53), or decreased (negative effects, n = 24). The positive effects lasted for about 1 week and the negative effects for 3 days. Conclusion: While the frequency of psychological effects following blood donation identified by our study was comparable to others, the changes of the psychological state in our donors were traceable for a longer period than previously acknowledged.
© 2021 The Author(s). Published by S. Karger AG, Basel
Introduction
Maintaining a sufficient blood supply is a constant challenge for transfusion medicine. This is especially true for societies with an aging population [ 1 , 2 ]. The demographic change induces a shift from a younger to an older population, leading to a decline of eligible donors [ 3 - 5 ], while at the same time the increase in the elderly population will likely increase the demand for blood transfusion [ 4 , 6 - 8 ]. A better understanding of the bio-psychological and motivational factors of blood donation could help to establish new approaches to motivate and recruit blood donors. Many studies have addressed the motivational factors of blood donation [ 9 - 14 ] and adverse effects after blood donation [ 15 - 18 ]. However, only few investigations refer to positive psychological effects (in this study termed as “well-being”) after blood donation [ 13 , 19 - 26 ]. Previous qualitative studies provided some insights into the psychological effects after blood donation. Sojka and Sojka [ 22 ] identified in a retrospective study (with a self-administered questionnaire for 600 donors) the items “feeling of satisfaction,” “more alert,” and “feeling generally better” as positive effects of blood donation, while other authors found an increase in the well-being of blood donors ( n = 108) in contrast to a control group ( n = 108) emerging within 24 h after blood donation using the Multidimensional Mood Questionnaire (MDMQ) [ 21 , 27 ]. This questionnaire was also completed by first-time whole blood donors in a study from Jansen et al. [ 20 ], who found only minor changes in the donors’ well-being after blood donation. These changes in well-being were not associated with the return rate of donors. In a cross-sectional study from Denmark, 61% of blood donors experienced donation-related effects. The authors used a structured questionnaire that included both psychological (e.g., “energy”) and physiological (e.g., “dizziness,” “headache”) symptoms [ 24 ]. Another study by van den Hurk et al. [ 28 ] used self-administered questionnaires to identify motivational factors and health characteristics in a representative cohort ( n = 23,064) of the Dutch donor population. Positive effects (“feeling fit,” “less headache”) or negative effects (“lack of energy,” “dizzy”) after blood donation were reported by 4.6% and 13.9% of donors, respectively. Pre-donation symptoms (“headache,” “lack of energy”) occurred in 2.8% of donors. Beside psychological effects, other variables are well known to influence blood donors or may have a potential impact on donor well-being. In women, a low hemoglobin level has been described to be associated with increased vertigo [ 22 ] and dizziness [ 28 ] after blood donation, while 2 other studies reported an association between high pre-donation hemoglobin values and negative adverse effects in blood donors [ 18 , 29 ]; in addition, low blood pressure increases the risk for vasovagal reactions after blood donation [ 30 , 31 ] and other negative post-donation symptoms [ 28 ]. Furthermore, positive effects after blood donation were seen predominantly in donors with higher body mass index (BMI) [ 24 , 28 ] and positive smoking status [ 24 ]. In this study, we present quantitative data on changes of the psychological state after blood donation using a newly established Well-Being Questionnaire (WBQ) and its application in a group of 100 regular blood donors with a follow-up of 8 weeks.
Materials and Methods
This cross-sectional prospective study consisted of 2 parts and was performed during 5 consecutive months before the corona virus epidemic at the Department of Transfusion Medicine at the University Medicine Greifswald (18,500 whole blood donations/year). All participants were eligible for whole blood donation according to the national hemotherapy guidelines [ 30 ]. The study was approved by the local ethics committee of the University Medicine Greifswald and written informed consent was obtained from all participants.
Study – Part 1
Part 1 of this study was carried out to establish a questionnaire for the assessment of subjective changes in the well-being of whole blood donors after blood donation. Regular blood donors who had given at least 5 blood donations before were randomly asked in the waiting area of the blood donation center if they were willing to participate in an interview designed to yield information about psychological and physiological changes they had perceived after blood donation in the past. The interviews were conducted by the same interviewer in a face-to-face setting, recorded, and paper-based documented. The participants were asked whether they did “feel better, unchanged, or worse” after donating blood with regard to 4 time periods (the first few hours after donation, the first day after donation, 1–2 weeks after donation, and 3–4 weeks after donation). Then, the participants were encouraged to describe the psychological and/or physiological changes they had experienced during previous blood donations using their own words. The aim was to identify yet unrecognized effects or behavioral changes after blood donation. After that, the participants were asked preselected questions on effects after blood donation described in the literature. These questions addressed 10 common mood- and behavior-related dimensions (physical fitness; concentration; physical well-being; energy level; mood; alterations in the sleep behavior; satisfaction; creativity; resilience; spirit of initiative) and the dimension of observer-related changes (reaction or comments of family members or friends about the own behavioral changes). Questions were, for example: “Did you experience changes in your concentration after blood donation; e.g., while driving, reading, at work/housekeeping?” The recorded answers of participants were analyzed by the authors using a descriptive approach and frequencies of statements were counted. The most frequently mentioned changes after blood donation were then used to develop quantitative questions for the WBQ (Fig. 1 ) used in study part 2. Also, additional adjectives (e.g., “more or less alert” for the item concentration ) were given to allow an easier understanding of the items (Fig. 1 ). To enable participants to give quantitative “translations” of changes in their well-being (per each item) in comparison to the situation before blood donation, the items were presented on a scale. The scale ranged from –5 to +5; –5 was the maximal negative decline on the item and +5 the maximal increase, while 0 indicated “no change” compared to the average well-being for the past 4–8 weeks before blood donation.
Well-Being Questionnaire of study part 2. Instruction for participants: “Please fill out this questionnaire in the given scales. The 0 corresponds to the average level you would give yourself for the past 4–8 weeks.”
Study – Part 2
For part 2, regular whole blood donors with at least 3 previous blood donations were enrolled in the study before blood donation. Participants had to assess their well-being at 7 time points. During the first 3 time points, a paper-based version of the WBQ (Fig. 1 ) was filled in by participants in the donor clinic 15–30 min before the donation process, during the donation process, and 15–30 min after donation. Thereafter, the WBQ was applied by standardized telephone interviews with the participants at 5 different time points after blood donation (5–7 [mean 6] h after donation, 22–26 [mean 24] h after donation, 3 days after donation, 1 week after donation, and 8 weeks after donation). For easier understanding, participants received a version of the WBQ for their own use at home. All interviews were performed by the same interviewer to reduce variability. The answers of the participants were documented in a database by the interviewer. Donors of part 2 received a remuneration of EUR 15 after completed participation.
We also included additional variables known as potential confounders of well-being of blood donors: age, gender [ 18 , 28 , 30 , 32 ], hemoglobin concentration [ 22 ], blood pressure [ 28 , 33 ], and BMI [ 34 ].
With the exception of blood pressure, the post-donation hemoglobin and BMI were not expected to change within 1 week after blood donation. We did not include items such as perceived needle pain, personal satisfaction, or personal interaction with the donor clinic staff, because these items had not been mentioned during the qualitative interviews by more than 25% of the regular blood donors. Furthermore, we had to keep the number of study questions within a manageable range during the multiple telephone interviews.
Analysis of the WBQ
To analyze the well-being after blood donation, the scores of the 7 items were summarized to the well-being score. At each time point, the well-being score could range from −35 (if all 7 items were judged “maximally negative”) to +35 (if all 7 items were judged “maximally positive”). The well-being score at each time point was compared with the baseline score. We calculated the baseline score from the well-being score obtained 15–30 min before blood donation and the well-being score obtained 8 weeks after blood donation divided by 2, as both the 15–30 min score and the 8 weeks score are very unlikely to be influenced by the blood donation. Then, we calculated a summary score for each donor. The summary score was obtained by subtracting the baseline score from the well-being scores obtained during the donation process, 15–30 min, 6 h, 24 h, 3 days, and 1 week after donation. By this approach, a delta value was obtained for each time point (well-being score at time point minus baseline score). For example, if the well-being score was 14 at 15–30 min before donation and 10 at 8 weeks after donation, the resulting baseline score was 12. If at 24 h after donation the well-being score was 4, this resulted in a delta of −8. If the well-being score at 1 week after donation was 20, this resulted in a delta of +8. All delta variables of an individual participant were aggregated to the summary score. Next, we sketched out a diagram for the donors with their well-being scores over time. According to the individual curve of the well-being score, we assigned the donors to 1 of 3 different effect groups (positive effects, no effects, and negative effects after blood donation) by visual mapping. This was performed independently by all study authors. In the few cases of discrepant grouping, consensus was obtained by discussion. From the curves we then deducted the threshold values of the summary score for the 3 groups.
To summarize the different items of the WBQ to the well-being score, the internal consistency of the questionnaire was verified by Cronbach’s α coefficient (function of the number of test items and the average inter-correlation among the items) for the different time points. This coefficient displays excellent internal consistency for a questionnaire with α ≥ 0.9, good internal consistency with 0.7 ≤ α < 0.9, and acceptable internal consistency with 0.6 ≤ α < 0.7. The internal consistency for a questionnaire is usually considered to be insufficient at a Cronbach’s α ≤ 0.5 [ 35 ].
Differences between the 3 groups according to the summary score and differences in the characteristics of the participants (age, gender, blood pressure, day time of blood donation, hemoglobin concentration) were calculated by Kruskal-Wallis test or Mann-Whitney U test; p values <0.05 were regarded as significant. Values are expressed as mean values ± standard deviation. Statistical analyses were computed by SPSS 21 for Windows.
For the qualitative study, we enrolled 24 females (mean age 42.67 ± 11.80 years; range 24–59) and 18 males (mean age 39.28 ± 8.58 years; range 25–50).
The frequency of the commonly experienced psychological and physiological dimensions described by the participants of part 1 were counted numerically (absent/present). Seven of the described dimensions were experienced after previous blood donations by at least 25% of the participants. These were mood (mentioned by n = 21 blood donors), resilience ( n = 20), spirit of initiative ( n = 12), concentration ( n = 11), physical well-being ( n = 24), energy level ( n = 27), and satisfaction ( n = 24) . These dimensions were used to develop the WBQ for study part 2 (Fig. 1 ).
A total of 104 regular whole blood donors were enrolled, of whom 4 participants were excluded from further analysis because of missing data during the follow-up period. The characteristics of the 100 participants are shown in Table 1 .
Characteristics of participants ( N = 100)
The Cronbach’s α coefficient of the WBQ (Table 2 ) exceeded 0.7 (range 0.911–0.795) in all analyses, which indicates good internal consistency of the questionnaire across the investigation period or, in other words, the items in the WBQ all reliably measure the same latent variable (well-being).
Cronbach’s α score of the well-being measure with 7 items for the different time points
According to the summary score, 23 donors showed positive effects on well-being after blood donation (aggregated summary score between 15 and 86.5), 53 donors showed no effects (summary score between −6.4 and 14.9), and 24 showed negative effects (summary score between −6.5 and −61.5). Representative examples for the individual curves of the well-being scores are shown in Figure 2 a for a donor with positive effects, in Figure 2 b for a donor without effects, and in Figure 2 c for a donor with negative effects after blood donation. The respective kinetics of the well-being scores in the different study groups are shown in Figure 2 d. Donors with positive effects had a significantly higher well-being score compared to donors with no or negative effects already 15–30 min after blood donation (Mann-Witney U test; p = 0.031). Furthermore, this higher well-being score of donors with positive effects lasted for a mean of 1 week after donation (Mann-Witney U test; p = 0.003). In contrast, donors with negative effects had a significantly lower well-being score from 6 h to 3 days after donation compared to donors with positive (Mann-Witney U test; p = 0.04) or no effects ( p = 0.014). Overall comparison of the 3 groups in a variance analysis showed significantly different well-being scores at the time points 15–30 min before blood donation (Kruskal-Wallis test; p = 0.016), 6 h ( p = 0.007), 24 h ( p = 0.003), 72 h ( p = 0.002), and 1 week ( p = 0.0011) after blood donation.
a Individual curve of the well-being score over 8 weeks from a blood donor with positive effects after whole blood donation. b Individual curve of the well-being score over 8 weeks from a blood donor with no effects after whole blood donation. c Individual curve of the well-being score over 8 weeks from a blood donor with negative effects after whole blood donation. d Summary of the well-being scores of the 3 study groups ( n = 100). The well-being scores of each participant were determined by adding all item scores obtained at a certain day. Of the 100 enrolled blood donors, n = 23 showed positive effects on their well-being (summary score between 15 and 86.5); n = 53 donors showed no effects (summary score between −6.4 and 14.9); and n = 24 donors showed negative effects (summary score between −6.5 and −61.5). The changes in the well-being scores over the observation period are given as mean ± 2 SD. * indicates significant differences between the 3 groups. All data points refer to the time points given on the x -axis but are slightly moved in the graph for better readability.
Participants with low diastolic blood pressure (<80 mm Hg) prior donation had a higher risk for negative effects 15–30 min and 6 h after donation (Kruskal-Wallis test; p = 0.045 and p = 0.014) compared to blood donors with higher diastolic blood pressure (≥80 mm Hg, odds ratio 5.32, 95% confidence interval 1.83–15.49). Furthermore, younger blood donors (≤35 years) had a lower well-being score compared to blood donors >35 years of age 6 h after donation (Kruskal-Wallis test; p = 0.006).
Donors with positive, negative, and no effects after donation were similarly experienced with 23.1, 19.2, and 19.7 previous blood donations, respectively, before study participation (Kruskal-Wallis test; p = 0.636). Thirty donors in the study had equal or fewer than 10 whole blood donations before study participation Positive, negative, or no effects occurred after blood donation in this study in 5, 17, and 8 donors, respectively. Another 40 participants were experienced donors with more than 20 donations. Positive, negative, or no effects were reported in this subgroup by 11, 9, and 20 donors, respectively.
In this study, we show that blood donation influences the well-being of donors over several days. About 25% of donors experienced a positive effect with a mean duration of 1 week, 25% of donors experienced a negative effect with a mean duration of 3 days, while in half of the donors, blood donation had no effects on well-being.
These findings are very similar to those of other studies. Sojka and Sojka [ 22 ] identified donors with positive or negative and mixed positive and negative effects in 29%, 19%, and 6% of donors, respectively, and observed no changes in well-being in about half of the donors [ 22 ]. Hinrichs et al. [ 21 ] also found positive (26.5%) and negative (23.5%) effects of blood donation on well-being in the same proportions of blood donors. The authors of the Danish Blood Donor Study determined in a cohort of 6,073 blood donors a prevalence of positive, negative, and mixed effects after blood donation with 18%, 29%, and 14%, respectively [ 24 ].
However, in a Dutch cohort study, positive and negative effects after blood donation were reported to occur in 4.6% and 13.9% of whole blood donors, respectively [ 28 ]. Differences in the prevalence of effects might be related to the questionnaire phrasing or the study design. While van den Hurk et al. [ 28 ] focused on physical effects (“feeling fit,” “lack of energy,” or “dizziness”), we asked donors for their well-being related to 7 different psychological dimensions. Together, 5 studies in Germany, the Netherlands, Denmark, and Sweden describe that at least 30% of blood donors experience either psychological or physical effects after blood donation. This makes it rather likely that this finding is generalizable for a Middle and Northern European population.
Further evidence of a common effect is provided by the rather similar findings in the qualitative interviews we used in part 1 of our study to generate the questionnaire and in the studies by others using a self-administrated open-labelled questionnaire (identified effects, e.g., “feeling of satisfaction,” “more alert,” “feeling better,” “tired,” and “diminished physical capacity” [ 22 ] or “feeling fit,” “lack of energy,” and “dizziness” [ 24 , 28 ]).
As outlined by others, the positive donation-related effects may be helpful in the recruitment of new donors and may motivate infrequent donors to donate more frequently [ 21 , 22 , 24 , 28 ]. While Jansen et al. [ 20 ] found that psychological effects had probably no impact on return rates of first-time donors, Suemnig et al. [ 13 ] showed that physical effects (“feeling physically better after donation”) were a motivational factor to return to blood donation, especially for older donors (≥50 years).
Kinetics of the Changes in Well-Being
The participants in our study reported that positive effects began within the first 30 min after blood donation. This is in concordance with other studies; for example, Hinrichs et al. [ 21 ] reported that positive effects occurred 15–30 min after blood donation; similar but only minor positive changes in the agitation level of first-time blood donors were noted in the first 30 min after blood donation in a study by Jansen et al. [ 20 ] who used the same questionnaire as Hinrichs et al. [ 21 ]. A higher elation and decreased anxiety score of donors up to 60 min after donation were seen in study by Zillmer et al. [ 26 ]; and Sojka and Sojka [ 22 ], who used a retrospective approach in their study, report the putative onset of effects within 1 h after donation. This study also found that positive effects last longer than negative effects [ 20 ], which is similar to our results, where the positive changes in well-being lasted for 1 week and the negative effects for 3 days.
Other Cofactors
The number of previous blood donations had no major impact on changes in well-being, in concordance with results from other investigators [ 21 , 22 , 28 ]. Notably, the study by van den Hurk et al. [ 28 ] found neither positive nor negative effects associated with the number of prior blood donations in a representative cohort of over 23,000 blood donors, with most participants having experienced a total of 5 or more donations [ 28 ]. Interestingly, Sojka and Sojka [ 22 ], who included donors with fewer than 5 donations, found no differences in the distribution of effects according to the number of previous blood donations [ 22 ]. However, as we only enrolled donors with at least 3 previous blood donations (the vast majority with at least 5 previous blood donations), we do not know whether this might be different in donors with only 1 or 2 previous blood donations. Also, our observation that younger donors (≤35 years) had a significantly lower well-being score 6 h after blood donation is comparable to results of 2 cohort studies from Sweden [ 22 ] and Denmark [ 24 ], who described more negative psychological effects in younger donors than in older donors. This might in part be related to an increased rate of vasovagal reactions in younger blood donors [ 30 , 31 ], especially if they are unexperienced donors. While Teglkamp et al. [ 24 ] found positive effects associated with age, we and others [ 21 , 22 , 28 ] could not generally confirm this association.
In contrast to other studies [ 21 , 22 , 28 ], we observed no association between donation-induced changes in the donors’ well-being and the pre-donation hemoglobin concentration. We also found no significant differences in well-being depending on gender or BMI, while others observed a higher rate of negative effects after whole blood donation in females compared to males [ 21 , 24 , 28 ] and a correlation of a higher BMI with negative symptoms before (“lack of energy,” “headache”) [ 26 ] or positive symptoms (“alleviated headache”) after blood donation [ 24 ]. Finally, van den Hurk et al. [ 28 ] and the present study suggest that donors with a lower diastolic blood pressure experience more negative effects after blood donation in comparison to donors with a higher diastolic blood pressure, while a systematic review found no evidence of an increased risk of adverse physical effects after blood donation in subjects with hypotension prior to the donation [ 36 ].
Study Limitations
Due to the single-center design of our study, we cannot exclude that specific local factors had an effect on the emotional reactions of the donors after blood donation, for example, personal interaction between the donor and staff of the donor clinic. Furthermore, the results may not be transferable to the donor cohort of other blood donor services due to the large number of young participants in our study, reflecting the location of our donor center within a small university city. Future studies should be performed in a donor population of a large national or regional blood service. The study should enroll young and older participants to confirm our results, ideally in a prospective manner over at least 1 week after donation.
We aimed to generate a set of 7 questions relevant to blood donation based on study part 1 with qualitative interviews. However, we did not extensively validate the selected items using different cohorts independent of blood donation. The quantitative approach to the questions allowed us to summarize the items to a total score. However, despite controlling with Cronbach’s α test for consistency we cannot exclude that we lost some information provided by the individual questions.
We summarized the scores 15–30 min before donation and 8 weeks after donation as baseline scores. Potentially, the values obtained shortly before blood donation had been influenced by some form of anxiety or headache as shown by van den Hurk et al. [ 28 ] and Teglkamp et al. [ 24 ]. However, as outlined above, only “trained” regular blood donors with at least 3 previous donations were enrolled in study part 2, which makes the impact of anxiety factors probably low.
Our study is a correlational study, hence any observed variability in well-being ratings over time may reflect life experiences that have nothing to do with blood donation (e.g., serious family event; car accident). Controlling non-blood donation variables by a matched population of individuals who did not donate blood was not feasible in the present study. Furthermore, we analyzed the change in variables over 8 weeks, which should have levelled out some of the non-blood donation related effects which may have impacted well-being.
In summary, the frequencies of positive and negative effects in donors following blood donation seem to be comparable among at least 3 different studies, including the present study, with about 25% of donors experiencing positive psychological effects after blood donation and about the same percentage of donors experiencing negative psychological effects after blood donation. Given these rather reproducible findings, further studies should assess whether physiological mechanisms impact these changes in psychological factors to identify potential biomolecular changes induced by blood donation.
Conflict of Interest Statement
The authors declare that they have no conflicts of interest relevant to the manuscript submitted to Transfusion Medicine and Hemotherapy .
Statement of Ethics
This study was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. The study was approved by the local ethics committee of the University Medicine Greifswald and written informed consent was obtained from all participants. All authors had full access to all data including all statistical reports and tables used in the manuscript.
Funding Sources
We acknowledge support for the Article Processing Charge from the DFG (German Research Foundation, 393148499) and the Open Access Publication Fund of the University of Greifswald.
Author Contributions
M.E., H.J.G., and A.G. conceived and designed the study. M.E., A.S., U.A., and A.G. acquired, analyzed, or interpreted the data, drafted the article or provided critical revision for important intellectual content, and provided final approval of the version to be published. All authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved.
- Crossref (DOI)
- Riga A, Sapey T, Bacanu M, Py J-Y, Dehaut F. Blood donors – Serious adverse reactions (SAR) 2010-2014 EFS Châteauroux, France. Transfus Clin Biol . 2015;22:62–5.
- Uma S, Arun R, Arumugam P. The knowledge, attitude and practice towards blood donation among voluntary blood donors in Chennai, India. J Clin Diagn Res . 2013;7:1043–6.
- Steyer R. Der mehrdimensionale Befindlichkeitsfragebogen: MDBF . Göttingen: Hogrefe, Verlag für Psychologie; 1997.
Author Contacts
Article / publication details.
Received: March 10, 2021 Accepted: May 27, 2021 Published online: August 23, 2021 Issue release date: April 2022
Number of Print Pages: 9 Number of Figures: 2 Number of Tables: 2
ISSN: 1660-3796 (Print) eISSN: 1660-3818 (Online)
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This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
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Blood safety and availability
- Of the 118.5 million blood donations collected globally, 40% of these are collected in high-income countries, home to 16% of the world’s population.
- In low-income countries, up to 54 % of blood transfusions are given to children under 5 years of age; whereas in high-income countries, the most frequently transfused patient group is over 60 years of age, accounting for up to 76% of all transfusions.
- Based on samples of 1000 people, the blood donation rate is 31.5 donations in high-income countries, 16.4 donations in upper-middle-income countries, 6.6 donations in lower-middle-income countries and 5.0 donations in low-income countries.
- An increase of 10.7 million blood donations from voluntary unpaid donors has been reported from 2008 to 2018. In total, 79 countries collect over 90% of their blood supply from voluntary unpaid blood donors; however, 54 countries collect more than 50% of their blood supply from family/replacement or paid donors.
- Only 56 of 171 reporting countries produce plasma-derived medicinal products (PDMP) through the fractionation of plasma collected in the reporting countries. A total of 91 countries reported that all PDMP are imported, 16 countries reported that no PDMP were used during the reporting period, and 8 countries did not respond to the question.
- The volume of plasma for fractionation per 1000 population varied considerably between the 45 reporting countries, ranging from 0.1 to 52.6 litres, with a median of 5.2 litres.
National blood policy and organization
Blood transfusion saves lives and improves health, but many patients requiring transfusion do not have timely access to safe blood. Providing safe and adequate blood should be an integral part of every country’s national health care policy and infrastructure.
WHO recommends that all activities related to blood collection, testing, processing, storage and distribution be coordinated at the national level through effective organization and integrated blood supply networks. The national blood system should be governed by national blood policy and legislative framework to promote uniform implementation of standards and consistency in the quality and safety of blood and blood products.
In 2018, 73 % of reporting countries, or 125 out of 171, had a national blood policy. Overall, 66% of reporting countries, or 113 out of 171, have specific legislation covering the safety and quality of blood transfusion, including:
- 79% of high-income countries
- 63% of middle-income countries
- 39% of low-income countries.
Blood supply
About 118.54 million blood donations are collected worldwide. 40% of these are collected in high-income countries, home to 16 % of the world’s population.
About 13 300 blood centres in 169 countries report collecting a total of 106 million donations. Collections at blood centres vary according to income group. The median annual donations per blood centre is 1 300 in the low-income countries, 4 400 in lower-middle-income countries and 9 300 in upper-middle-income countries, as compared to 25 700 in high-income countries.
There is a marked difference in the level of access to blood between low- and high-income countries. The whole blood donation rate is an indicator for the general availability of blood in a country. The median blood donation rate in high-income countries is 31.5 donations per 1000 people. This compares with 16.4 donations per 1000 people in upper-middle-income countries, 6.6 donations per 1000 people in lower-middle-income countries, and 5.0 donations per 1000 people in low-income countries.
60 countries report collecting fewer than 10 donations per 1000 people. Of these, 34 countries are in the WHO African Region, four in the WHO Region of the Americas, four in the WHO Eastern Mediterranean region, four in the WHO European Region, five in the WHO South-Eastern Asia Region, and nine in the WHO Western Pacific Region. All are low- or middle-income countries.
Blood donors
Age and gender of blood donors.
Data about the gender profile of blood donors show that globally 33% of blood donations are given by women, although this ranges widely. In 15 of the 113 reporting countries, less than 10% of donations are given by female donors.
The age profile of blood donors shows that, proportionally, more young people donate blood in low- and middle-income countries than in high-income countries. Demographic information of blood donors is important for formulating and monitoring recruitment strategies.
Types of blood donors
There are 3 types of blood donors:
- voluntary unpaid
- family/replacement
An adequate and reliable supply of safe blood can be assured by a stable base of regular, voluntary, unpaid blood donors. These donors are also the safest group of donors as the prevalence of bloodborne infections is lowest among this group. World Health Assembly resolution WHA63.12 urges all Member States to develop national blood systems based on voluntary unpaid donations and to work towards the goal of self-sufficiency.
Data reported to WHO shows significant increases of voluntary unpaid blood donations in low- and middle-income countries:
- An increase of 10.7 million blood donations from voluntary unpaid donors from 2008 to 2018 has been reported by 119 countries. The highest increase of voluntary unpaid blood donations is in the South-East Asia Region (127%) followed by the Region of the Americas (81%) and Africa (81%). The maximum increase in absolute numbers was reported in the Western Pacific Region (4.15 million donations), followed by South-East Asia (3.05 million) and Africa (1.53 million donations).
- 79 countries collect more than 90% of their blood supply from voluntary unpaid blood donations (38 high-income countries, 33 middle-income countries and eight low-income countries). This includes 64 countries with 100% (or more than 99%) of their blood supply from voluntary unpaid blood donors.
- In 54 countries, more than 50% of the blood supply is still dependent on family/replacement and paid blood donors (eight high-income countries, 36 middle-income countries and 10 low-income countries).
Blood screening
WHO recommends that all blood donations should be screened for infections prior to use. Screening for HIV, hepatitis B, hepatitis C, and syphilis should be mandatory. Blood screening should be performed according to quality system requirements. Of reporting countries, 10 are not able to screen all donated blood for one or more of the above infections.
99.8% of the donations in high-income countries and 99.9% in upper-middle-income countries are screened following basic quality procedures, as compared to 83% in lower-middle-income countries and 76 % in low-income countries. The prevalence of transfusion-transmissible infections in blood donations in high-income countries is considerably lower than in low- and middle-income countries (Table 1).
Table 1. Prevalence of transfusion-transmissible infections in blood donations (Median, Interquartile range (IQR)), by income groups
These differences reflect the variation in prevalence among population who are eligible to donate blood, the type of donors (such as voluntary unpaid blood donors from lower risk populations) and the effectiveness of the system of educating and selecting donors.
Blood processing
Blood collected in an anticoagulant can be stored and transfused to a patient in an unmodified state. This is known as ‘whole blood’ transfusion. However, blood can be used more effectively if it is processed into components, such as red cell concentrates, platelet concentrates, plasma and cryoprecipitate. In this way, it can meet the needs of more than one patient.
The capacity to provide patients with the different blood components they require is still limited in low-income countries: 38% of the blood collected in low-income countries is separated into components, 75% in lower-middle-income countries, 96% in upper-middle-income countries, and 96% in high-income countries.
Supply of plasma-derived medicinal products (PDMP)
World Health Assembly resolution WHA63.12 urges Member States to establish, implement and support nationally coordinated, efficiently managed and sustainable blood and plasma programmes, according to the availability of resources, with the aim of achieving self-sufficiency. It is the responsibility of individual governments to ensure sufficient and equitable supply of plasma-derived medicinal products, namely immunoglobulins and coagulation factors, which are needed to prevent and treat a variety of serious conditions that occur worldwide.
Only 56 of 171 reporting countries produce plasma-derived medicinal products (PDMP) through the fractionation of plasma collected in the reporting country. A total of 91 countries reported that all PDMP are imported, 16 countries reported that no PDMP were used during the reporting period, and 8 countries did not respond to the question.
Around 19 million litres of plasma from 45 reporting countries was fractionated for the production of PDMP during the year. This includes around 31% of plasma recovered from the whole blood donations. The volume of plasma for fractionation (and processing for PDMPs) per 1000 population varied considerably between the reporting countries, ranging from 0.1 to 52.6 litres, with a median of 5.2 litres.
Clinical use of blood
Unnecessary transfusions and unsafe transfusion practices expose patients to the risk of serious adverse transfusion reactions and transfusion-transmissible infections. Unnecessary transfusions also reduce the availability of blood products for patients who are in need.
WHO recommends the development of systems, such as hospital transfusion committees and haemovigilance, to monitor and improve the safety of transfusion processes. In this regard:
- 128 countries have national guidelines on the appropriate clinical use of blood: 32 countries in the African region (74% of reporting countries in the region), 23 in the Americas (70%), 12 in the Eastern Mediterranean (67%), 33 in Europe (80%), 9 in the South East Asia (90%), and 19 in the Western Pacific (76%).
- Transfusion committees are present in 48% of the hospitals performing transfusions: 62% in hospitals in high-income countries, 35% in upper-middle-income countries, 31 in lower-middle-income countries and 25% in low-income countries.
- Systems for reporting adverse transfusion events are present in 55% of the hospitals performing transfusions: 74% in hospitals in high-income countries, 35% in upper-middle-income countries, 22% in lower-middle-income countries and 18% in low-income countries,
- 49% of reporting countries have a haemovigilance system. The European region has the highest percentage of countries with haemovigilance systems (81%), followed by the Western Pacific (50%), the Eastern Mediterranean (50%), Africa (40%), South-East Asia (40%), and the Americas (21%).
Blood transfusions
There are great variations between countries in terms of age distribution of transfused patients. For example, in high-income countries, the most frequently transfused patient group is over 60 years of age, which accounts for up to 76% of all transfusions. In low-income countries, up to 54% of transfusions are for children under the age of 5 years.
In high-income countries, transfusion is most commonly used for supportive care in cardiovascular surgery, transplant surgery, massive trauma, and therapy for solid and haematological malignancies. In low- and middle-income countries it is used more often to manage pregnancy-related complications and severe childhood anaemia.
WHO response
The risk of transmission of serious infections, including HIV and hepatitis, through unsafe blood and chronic blood shortages brought global attention to the importance of blood safety and availability. With the goal of ensuring universal access to safe blood and blood products, WHO has been at the forefront to improve blood safety and availability, and recommends the following integrated strategy for blood safety and availability:
- Establishment of a national blood system with well-organized and coordinated blood transfusion services, effective evidence-based and ethical national blood policies, and legislation and regulation, that can provide sufficient and timely supplies of safe blood and blood products to meet the transfusion needs of all patients.
- Collection of blood, plasma and other blood components from low-risk, regular, voluntary unpaid donors through the strengthening of donation systems, and effective donor management, including care and counselling.
- Quality-assured screening of all donated blood for transfusion-transmissible infections, including HIV, hepatitis B, hepatitis C and syphilis, confirmatory testing of the results of all donors screen-reactive for infection markers, blood grouping and compatibility testing, and systems for processing blood into blood products (blood components for transfusion and plasma derived-medicinal products), as appropriate, to meet health care needs.
- Rational use of blood and blood products to reduce unnecessary transfusions and minimize the risks associated with transfusion, the use of alternatives to transfusion where possible, and safe and good clinical transfusion practices, including patient blood management.
- Step-wise implementation of effective quality systems, including quality management, standards, good manufacturing practices, documentation, training of all staff, and quality assessment.
WHO supports countries in developing national blood systems to ensure timely access to safe and sufficient supplies of blood and blood products and good transfusion practices to meet patient needs. WHO provides policy guidance and technical assistance to countries for ensuring universal access to safe blood and blood products and work towards self-sufficiency in safe blood and blood products based on voluntary unpaid blood donation to achieve universal health coverage.
*Data source : This fact sheet is based on data obtained through the WHO Global Database on Blood Safety from 108 countries for the year 2018. To give a more complete overview of the global situation, data for the year 2017 have been used for 40 countries and data for the year 2015 have been used for 23 countries, where current data are not available. Overall, responses received from 171 countries cover 97.5 % of the world’s population.
World Blood Donor Day
- Yearly campaign, 14 June
More about blood safety
- Global database on blood safety
- WHO's work on blood safety
- Blood safety: topical overview
- Towards 100% voluntary blood donation
- Blood donor selection
- Protecting the blood supply during infectious disease outbreaks: guidance for national blood services
- A guide to establishing a national haemovigilance system
- Guidance on increasing supplies of plasma-derived medicinal products in low- and middle-income countries through fractionation of domestic plasma
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