key: cord-0710355-ztczjtws
authors: Saleh, Rana Ahmed; Khalil, Hala; Alsaleh, Mahasen; Almeharish, Amani; Mohammed, Viqaruddin; Alhumaidan, Hind; Saleh, Renad
title: Voluntary and non‐voluntary blood donations among doctors
date: 2021-10-05
journal: Health Sci Rep
DOI: 10.1002/hsr2.377
sha: 3428181076598f7ee0b36ee63e7f605f063eb4c0
doc_id: 710355
cord_uid: ztczjtws

BACKGROUND: Physicians may be an important source of blood donations as they are more likely to be familiar with the importance of donating and the donation process. The aim of this study is to report physicians' knowledge, attitudes, and practices towards voluntary and non‐voluntary blood donations. STUDY DESIGN AND METHODS: This was a cross‐sectional study conducted at King Faisal Specialist Hospital and Research Centre (KFSH&RC), Saudi Arabia. One‐hundred‐and‐sixteen physicians and dentists responded to an online structured questionnaire sent to their institutional emails. RESULTS: Sixty‐eight percent of participants (79% of males and 43% of females) reported previously having donated blood. Eighty‐six percent of donors had previously donated on a voluntary basis, whereas 31% of donors had previously donated for a specific person. A recent donation within 5 years was associated with the younger age group and knowledge of the minimum interval between donations. Fifty‐six percent of participants agreed with using replacement donations. Compared to participants in the youngest age group (25‐35 years), older participants in the age groups (46‐55 years) and (>55 years) were less likely to express intention to donate in the next 6 months (OR 0.289, P = .022 and OR 0.083, P = .004, respectively). Participants reporting poor nutritional status or other medical reasons as a barrier to donating blood were less likely to intend to donate (OR 0.146, P < .001). Among previous donors, intention to donate was associated with a recent donation within 1 year (OR 27.13, P = .002) and having had a pleasant donation experience (OR 14.98, P < .001). CONCLUSION: Blood donation practices are strongly tied to physicians' gender and age and their knowledge of the donation process. The most significant barrier to blood donation was found to be nutritional and medical status.

Blood transfusions are life-saving interventions in the settings of acute blood loss, major surgeries, and hematological diseases. Increasing donor recruitment and securing a sustainable supply of safe blood products is an important public health issue in transfusion medicine.

While voluntary, non-remunerated donors are usually motivated by altruistic intentions, 1 blood donations may also be obtained from non-voluntary sources-such as in the case of replacement donors (individuals who donate on behalf of a family member or friend as a prerequisite before an elective procedure) and statutory donors (those who donate for legislative purposes such as obtaining a driving license). There are also paid donors who provide blood commercially.

In Saudi Arabia, hospitals under the Ministry of Health (MOH)

share centralized blood banks run by the respective regional MOH, whereas other independent hospitals run their own blood transfusion service. 2 The majority of blood donations in Saudi Arabia are nonvoluntary similar to the trend in developing countries. 3 Studies in AlKhobar, for example, reported that non-voluntary blood donations made up 85.2% of the donor pool between 1992 and 1998 and 81% of the pool between 1996 and 2000. 4, 5 Most hospitals employ a "No Blood -No Operation" policy, whereby patients are required to arrange a replacement donation before elective surgeries, and this is typically sourced from the patient's family member or acquaintance. 2 Various surveys have reported the rate of non-voluntary donations among Saudi donors to range from 15% to 64%. [6] [7] [8] Replacement donations are less than ideal, since donors tend to have short-lived motives and are less likely to be retained. 9 Furthermore, there may be ethical implications in insisting for replacement donations. Family members or friends of patients may be burdened with expectations to donate, and they might omit disclosing risk factors during blood donation in order to avoid social stigma. This in turn could increase the risk of infected blood products. Studies have shown that voluntary sources are associated with the lowest risks of infected products 10 and as such, the World Health Organization (WHO) and Saudi Arabian Ministry of Health aim towards achieving an entirely voluntary blood pool. 4 Few studies in Saudi Arabia have explored factors associated with blood donations, the results of which have mainly been consistent with those reported in other countries. [11] [12] [13] [14] In terms of demographic characteristics, donors are more likely to be male, to belong to the middle-age group (30-50 years) , to be married, and to have higher educational levels. 8, 15 The most common reason for non-donors not to donate is not being asked. 7 In one survey, half of 316 non-donors reported they had been asked to donate blood; reasons cited by this group for not donating included fear, medical reasons, and lack of time. 6 Other reported barriers to donating blood are site inaccessibility, perceived possibility of acquiring infection, and anticipation of possible need to donate to a family member in the future. 8 Retaining previous donors is a further area of research when strategizing blood procurement, especially for donor groups with a rare blood type or low-risk status for infection. 9 Returning donors are more likely to be older and to have higher educational levels. Blood donation experience and perceived well-being after donating also affect future intention to donate. 9, 16 Studies have investigated the perceived effects of interventions such as gifts, free health checkups, blood credits, time-off work, and monetary compensation on donors' intentions to donate again. The effects of these motivators appear to vary according to donor characteristics. Older donors and long-time donors are less likely to report being influenced by compensatory interventions compared to their younger counterparts. 10 Physicians, by virtue of their profession, should be especially aware of the importance of blood donations and should also be familiar of the donation process and its negligible risks. They may therefore be expected to be a promising source of blood donations; however, observational data suggest that this is not the case. A study that recruited potential donors from a university hospital, for example, found that only 3.1% of respondents were physicians. 17 In a local college survey, medical and science students were no more likely to donate blood than students from other disciplines, suggesting that donation practices may ultimately be a social attribute. 6 Among healthcare professionals, however, physicians do appear to be the most likely to donate. [18] [19] [20] Barriers to donating blood in the physician population have mainly been investigated in developing countries. These have found that the primary reasons for not donating include not being asked, fear of needles or discomfort during the procedure, not being fit to donate, and fear of knowing their medical status. 18, [20] [21] [22] [23] During the peak of the COVID- 19 Forty-four percent of previous donors did not select any barrier to donating blood. None of the 22 donors who donated blood within the last 1 year selected any barrier to donation.

Eighty-six percent of donors previously donated on a voluntary basis, whereas 31% of donors (n = 24) reported having previously donated for a specific person as a replacement donation (19% of donors, n = 16) or for direct transfusion (17% of donors, n = 13) (see Table 4 ).

Hospital-based campaigns and messages had prompted blood donations for at least 20% of donors. Figure 1 illustrates the proportion of donors who donated within 1 and 5 years by the age group. Less than one-third of donors ( (>55 years). We did not find any significant difference in donation rates within 1 or 5 years between male and female donors (data not shown).

Fifty-eight percent of previous donors expressed intention to donate blood in the next 6 months compared to 33% of nondonors. Logistic regression was performed to identify predictors of intention to donate among participants ( proportion of non-donors held a neutral stance (P = .09). None of the variables tested predicted participants' agreement of replacement donations (Table 5 ). 

This is the first study in Saudi Arabia to report physicians' attitudes and practices towards blood donation. The study also explored perceptions of physicians towards replacement donations, a prevalent form of non-voluntary blood donation in Saudi Arabia. Females were more likely to report poor nutritional status such as anemia and low weight (39%) or other medical reasons (11%) as barriers to donating blood, similar to other reports. 28 Other studies have suggested that women are also more likely to report complications of procedures as barriers to donation, whereas men are more likely to report time constraints. 28 These differences were not observed in the current study, however, as previously mentioned, our sample was relatively homogenous and this could have resulted in decreased variation of experienced barriers, since male and female respondents would have similar work commitments, time constraints, and tolerances to procedures due to professional exposure. The most commonly cited reasons for deferrals among females are anemia, pregnancy, and lactation. 29 Authors have emphasized the need to encourage female donors to continue blood donations after pregnancy (which may be used for the transfusion of plasma and its derivatives) since they may be at risk of lapsing. 28 Although there was no significant difference in donor status by the age group, the study found that participants in the age group (25-35 years) were more likely to express intention to donate in the next 6 months compared to the older age groups (46-55 years) and (>55 years), but equally as likely as the age group (36-45 years) . This was in spite of a lack of association between age groups and reporting time constraints as a barrier to donating blood. Although it can be argued that intention to donate may not translate into actual donation practice and thus cannot be taken as a proxy to ascertain predictors, studies have shown that intention may indeed predict donation. 30, 31 The literature suggests that there is a global trend towards increasing donation rates among the younger generation. In one Saudi study that surveyed primary care patients, those in the age group (31-50 years) had the highest donation rates (57%). 8 A recent hospital-based study also found that the age group (26-35 years) had the greatest contribution to the donor pool (around 47%). 32 One

European study found that persons in the age group (30-44 years) were more likely to have donated blood compared to their younger and older counterparts in cohorts recruited across 1994 and 2014. As Possible explanations for these observations include the elimination of cultural barriers and increasing education and awareness among the general public in recent years. 34 We believe the same applies to the Saudi population and may explain why younger people are more likely to express intention to donate in the current study.

Voluntary blood donations did not become the norm among the general population until at least 1985, prior to which donations were mostly provided by paid non-Saudi donors or imported from other countries. 35 An alternative explanation for increased donations among the young is increasing efforts from blood banks directed at recruiting younger people, with the aim to retain them in the long term. 26, 33 There are no data to confirm whether Saudi transfusion services are currently employing this strategy. The increased use of online platforms to invite potential donors may be particularly effective among the youngest age groups, whether intentional or not. In the current study, four of seven of those who donated after an online media request were 25 to 35 years old, whereas responses to other modalities such as hospital campaigns were equally elicited across the different age groups (data not shown). However, in other studies, the effect of text messages on returning donations did not have a significant interaction with age. 36 Retention of donors is crucial for maintaining blood supplies, and almost half of the first-time donors will not return to donate after usually observed to donate more frequently than younger persons. 37 In the current study, we did not find any barrier specific to the older age groups that would preclude them from donating in recent years. Studies in other countries suggest that older donors are more likely to report time constraints and lack of center accessibility as reasons for lapsing. 28, 38 Unfortunately, our study did not capture the number of donations In addition, when a hospital-based replacement donor system has been in existence for many decades and demonstrated sustainability (in Saudi Arabia, accounting for 60% of donations 47 ), shifting to a completely voluntary recruitment strategy will be initially challenging and incur great costs. 48 Nevertheless, this is what will ensure longterm, sustainable donor pools, as well as minimize the risk of infected blood products. Transfusion services need to engage in wider campaigns to promote voluntary, non-renumerated blood donations and eventually aim to eliminate non-voluntary donor sources.

The study is limited by the low participation rates of invited physicians. The sample is likely to be biased, as individuals who respond are likely to differ from non-responders with regard to donation status. 9 The rates reported therefore may not represent those of the physician population in Saudi Arabia. Although inferences can be made on the association between different variables with donor status, intention to donate, and agreement of replacement donations, these should be interpreted with caution due to the study's potential selection bias. Of note, receiving an incentive message in the invitation email subject was not associated with any of the study's dependent or independent variables (age, gender, current job position, donor status, and intention to donate) or survey completeness (data not shown). Further studies should be conducted to reproduce the associations observed in our analyses.

Blood donation practices are strongly tied to physicians' gender and age and their knowledge of the donation process. The most significant barrier to blood donation was found to be nutritional and medical disease status. Half of the physicians surveyed agreed with mandating replacement donations before elective procedures.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors declare there is no conflict of interest. Dr. Hala Khalil had full access to the study data and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

The manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Hala Khalil https://orcid.org/0000-0003-0085-6987

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