SUMMARY ORIGINAL ARTICLE

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1 Transfusion Medicine, 2011, 21, doi: /j x ORIGINAL ARTICLE Iranian blood donors motivations and their influencing factors M. Maghsudlu & S. Nasizadeh Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran Received 12 January 2011; accepted for publication 5 April 2011 SUMMARY Aim: One of the challenges faced by blood transfusion services is the motivation of blood donors. The purpose of this study was to define the motivations of Iranian donors. Methodology: A total of volunteers were studied to evaluate their motivation for blood donation in 2003 and A questionnaire was designed covering sociodemographic characteristics, history of blood donation and a list of reasons for donating. The donor physician determined the donor s motivation after an interview. Motivation was classified as internal (altruistic and religious beliefs) and external motives. Results: The main motivations were 6629 (39 1%) altruistic, 6552 (38 6%) good for one s health and 1931 (11 4%) religious beliefs. It was shown that 8560 volunteers (50 5%) had internal motivations and 8395 (49 5%) had external motivations. Internal motivations were significantly higher in women, regular and educated donors. Conclusion: This study showed that internal motives are the main reason for blood donation in Iranian donors, especially in female, regular and high-educated donors. Thus, altruistic and religious messages can be emphasized in recruiting and retaining donors, particularly in this group. Nearly half of the donors were motivated by external factors mainly to improve their own health status, especially in older donors. This may be due to a psychological impact in which they feel improvement in their general health. As voluntary non-remunerated blood donation is defined without considering the motivational factor, one might consider a new term such as internal motivated voluntary blood donors in accordance with their motivation and efforts could be centered about recruiting these specific donors. Key words: blood donor volunteer, motivation. Human blood is rare, valuable and very much in need. The need for blood and its products is being felt more than ever as the population grows. Because the only source of supply is the blood donor, motivating and retaining donors is the only way to meet this need. Motivation of donors is one of the greatest challenges faced by the blood collection facilities today. Actually, this challenge has existed ever since the first blood donor donated blood (Badden, 1985). Motivation is a compelling force of activity which is directed towards meeting personal needs or goals. Abraham Maslow has shown these needs in the form of hierarchy (Maslow, 1943). This hierarchy is divided into basic or primary needs and advanced or secondary needs. Basic needs begin with physiological needs and then the need for safety, Correspondence: Mahtab Maghsudlu, Iranian Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, PO Box , Shahid Hemmat High Way, Next to Milad Tower, Tehran, Iran. Tel.: ; fax: ; m.maghsudlu@ibto.ir belonging and respect follows (Maslow, 1943). No doubt that blood donation is also an attempt to achieve these needs and everyone who wants to donate blood has a specific motivation. Some people expect monetary compensation; however, this system has long been phased out in Iran. Still another group expects response for their secondary needs such as social recognition, respect or simply self-gratification. Reviews of researches carried out in this field suggest that there are differences in the factors that motivate first-time donors with respect to that in repeated donors. At the first donation, external factors such as social pressure by peers or friends are important factors in the decision to donate, but become less important with repeat donation. Internal factors, such as a desire to help others, a sense of duty or desire to help the Red Cross, become more important over time (Pilliavin, 1990; Royse & Doochin, 1995). It has been shown that individuals who donate blood with motivations such as replacement of used blood or obtaining reward may not respond with true answers when asked about high-risk behaviour. Therefore, the Transfusion Medicine 2011 British Blood Transfusion Society 247

2 248 M. Maghsudlu and S. Nasizadeh use of these motivations is no longer acceptable. Fewer reward strategies are still in use to encourage people towards donation. Although true motivational factors are few, it is recommended (Ford & Wallace, 1975) that requesting people to donate blood be focused on several motivational factors. It is of utmost importance that all organizations involved in encouraging blood donation should have adequate information regarding the influential motivational factors in their donors in order to recruit low-risk blood donors. The Iranian Blood Transfusion Organization (IBTO), as a national blood transfusion service, is responsible for all blood transfusion activities from donor recruitment to the production and distribution of blood components. In 2009, a total blood units were collected in Iran, all of which were obtained from voluntary non-remunerated blood donors without any payment. Collection of 25 units per 1000 population is a good achievement according to the 2006 WHO map on blood donation rates (WHO, 2009), although a higher level is seen in some developed countries. This amount of blood has usually met most of our hospitals demand. Data collected by the Council of Europe reveal variable donation rates among different countries where the health care delivery status is apparently similar. Transfusion regimens and blood management can vary although similar outcomes are obtained, an obvious fact when comparing the Canadian and Australian health systems (Farrugia et al., 2010). However, it is necessary to obtain more information on our blood donors because the demand shows a steady increasing trend and more volunteers are being deferred at the donor selection process. In 2009 the deferral rate was 21 2% ( volunteers), whereas it rose to 22 4% ( volunteers) in Therefore, motivational factors in donors and their change over time must be closely evaluated and monitored. Knowledge of these factors not only helps in donor recruitment but also provides valuable information that may reduce the risk of transfusion transmissible infections. The purpose of this study was to investigate the motivational factors of Iranian blood donors with regard to their demographic characteristics and history of blood donations. MATERIALS AND METHODS A total of volunteers were studied to evaluate their reasons for blood donation. All fixed transfusion centres throughout the country participated in this study. Systematic random sampling was performed using the last digit on the donor sheet. All selected volunteers were entered into the study voluntarily and interviewed regardless of whether they were accepted for donation or not. A questionnaire was designed with two different sections. The first section of the questionnaire covered socio-demographic characteristics, i.e. age, sex, marital status, education level, job and residential place as well as past history of blood donation which was filled out by the receptionist. The terms of first-time, repeated and regular donors were given according to IBTO definitions (Maghsudlu et al., 2009): First-time donor is a donor who succeeds in donating blood for the first time. Repeated donor is a donor who has donated blood in the past, but not in the preceding 12 months. Regular donor is a donor who has donated twice or more within a period of 12 months. The second part consisted of a list of reasons for donating. The blood donor physician was responsible for interviewing the donor and asking about his/her main reason for donation. The mentioned reason was matched to the closest option in the list and marked by the attending physician just before performing the donor selection interview. When donors were asked about their main motivation in a pilot study, they would usually mention several factors. Therefore, based on projective techniques we decided that the first response was to be considered as the main motivation. Thus the physician was instructed to consider the first reason mentioned by the donor as the main motivation. In an attempt to reduce measurement bias, motivations were listed as phrases that might be expressed by volunteers as follows: Altruistic motive: helping patients, helping others, helping people, moral or social obligation, performing a good job, saving the life of others Religious belief: God satisfaction, vow with God, sacrificing Health screen: blood group test, physical examination of blood pressure, free test, any laboratory test, physician visit Good for one s health: any medical or psychological effect Curiosity: no specific reason, want to know how blood donation is like, curious about what is going on in a donation centre, having a new experience Social pressure: influence of a co-worker, friend, boss or family, insisted by one to donate At the end of the donor selection interview, the final outcome (accepted or deferred) was recorded in the questionnaire by the physician. Motives were then classified as internal (altruistic factor and a religious belief) or external (the remaining reasons). The study was approved by the Ethics Committee of the Research Center of the IBTO.

3 Blood donors motivations 249 Statistical analysis The frequencies of socio-demographic variables were calculated to define the studied population. Then a descriptive frequency of each motivational factor was computed. χ 2 and Fisher s exact tests were used to compare classified motivational factors within sociodemographics variables and history of donation. Finally, logistic regression was used to omit potential confounding variables. All statistical analyses were carried out with spss software (SPSS, Inc., Chicago, IL, USA). A level of P<0 05 was considered statistically significant. RESULTS Donors background Table 1 shows the socio-demographic characteristics and history of blood donation in participants. Their age ranged from 16 to 77, with a mean of 35 2 ± 15 5 years. Of the total participants, (85 1%) were male and 2530 (14 9%) were female; 5306 (31 3%) were single, (68 3%) were married and 62 (0 4%) were either divorced or widowed; (90 4%) were urban, 1315 (7 8%) were rural and the whereabouts of 312 (1 8%) persons were not available. Table 1. Demographic characteristics and history of blood donation of participants Characteristics Number (%) Sex Male (85 1) Female 2530 (14 9) Age (years) (30 5) (54 5) Older than (15) Place Urban (90 4) Rural 1315 (7 8) Education Illiterate 623 (3 7) Under diploma 5802 (34 2) Diploma 6477 (38 2) Academic 4053 (23 9) Marital status Single 5306 (31 3) Married (68 3) Donor status First-time 4088 (24 1) Repeated 6150 (36 3) Regular 6717 (39 6) Regarding employment status, 609 (3 6%) were unemployed, 548 (3 2%) were school teachers, 503 (3%) were soldiers, 5552 (32 7%) worked in the private sector, 2997 (17 7%) were employed in the public sector, 1618 (9 5%) were housewives, 1077 (6 4%) were college students, 874 (5 2%) were labourers and 757 (4 5%) were in the army or other organizations. Donors motivations The main motivations stated by donors were helping others 6629 (39 1%; 95% CI ), good for one s health 6552 (38 6%; 95% CI ), religious beliefs 1931 (11 4%; 95% CI ), curiosity 803 (4 7%; 95% CI 4 4 5), free health screen or laboratory tests 634 (3 7%; 95% CI 3 4 4), obtaining a blood donation card 326 (1 9%; 95% CI 1 7 2) and stated other reasons such as employment tests and social pressures 80 (0 5%; 95% CI ). The reasons given in the group of good for one s health were as follows: reduction in blood viscosity, blood purification, feeling better, mood changes, improvement of acne, losing weight and treatment for hyperlipidaemia. The motivations were then classified either as internal or external: 8560 blood donation volunteers (50 5%; 95% CI ) had internal and 8395 (49 5%; 95% CI ) had external motivations. Internal motivations were more significant in female (60 5%; 95% CI ), regular (53 3%; 95% CI ), year (52%; 95% CI ), married (51 5%; 95% CI ) and academic (51 5%; 95% CI ) blood donors as shown in Table 2. On the basis of the volunteers employment status, internal motivations were mostly seen in teachers, housewives and permanent army personnel. External motivations were dominant in soldiers, drivers and those in the private sector. In a regression logistic analysis, it was found that female sex (B = 0 7, P<0 001) had the most effect on internal motivations, with regular blood donations (B = 0 3, P<0 001), an education level higher than high school graduate (B = 0 2, P<0 001) and type of occupation had the most effect followed, respectively. Married status had no significant role as an internal or external motivation in the multivariate analysis. Evaluation of the final outcome showed that volunteers (83 3%) were accepted for donation and (14 2%) were deferred. Deferral rate was higher in the external motivation group as opposed to the internal motivation group (18 4 vs 10% respectively, P<0 001).

4 250 M. Maghsudlu and S. Nasizadeh Table 2. Motivations based on demographic characteristics and history of blood donations Internal External motivation motivation Characteristics Number (%) Number (%) P-value Sex Male 7030 (48 7) 7395 (51 3) Female 1530 (60 5) 1000 (39 5) P Age (years) (49 6) 2529 (50 4) (52) 4295 (48) P = > (44 8) 1361 (55 2) Place Urban 7676 (50 1) 7652 (49 9) Rural 694 (52 8) 621 (47 2) P = 0 36 Marital status Single 2565 (48 3) 2741 (51 7) Married 5965 (51 5) 5622 (48 5) P = 0 02 Education Illiterate 289 (46 4) 334 (53 6) Undergraduate 2936 (50 6) 2866 (49 4) Diploma 3244 (50 1) 3233 (49 9) P Academic 2091 (51 6) 1962 (48 4) Donor status First-time 1885 (46 1) 2203 (53 9) Lapsed 3092 (50 3) 3058 (49 7) P Regular 3583 (53 3) 3134 (46 7) [Correction added after online publication 11 July 2011: where table heading External motivation Number (%) should have read Internal motivation Number (%) and vice versa.] DISCUSSION This study showed that altruism is the main reason for blood donation in Iranian blood donors, which is consistent with similar studies in other countries (Oswalt, 1977; Pilliavin, 1990; Glynn et al., 2002; Hupfer et al., 2005; Misje et al., 2005; Nguyen et al., 2008; Randolph Steele et al., 2008). However, a sense of altruism was much higher in self-administrating studies. This may be due to different methods used to collect data. The self-administrating surveys enable participants to choose from a list of reasons (Choi & Pak, 2005). This list can direct the donor towards different reasons and leads them to choose a number of acceptable reasons in addition to his/her initial motive. Whereas in this study all of the questionnaires are marked by an interviewer physician rather than by blood donor themselves; therefore, comparing the two methods is slightly difficult. Our analysis showed a significant relationship among internal motivation and sex, history of blood donation and the donors educational level. Previous studies have also reported that women have higher levels of altruistic motivational factor, consequently leading to a greater response to altruistic messages by women (Glynn et al., 2002; Randolph Steele et al., 2008). The proportion of female blood donors is significantly lower than male in Iran; therefore more efforts must be made to attract female donors especially since they have more altruistic motivation. It is noteworthy that repeated blood donation, especially regular donation, was also associated with higher levels of internal motivational factor. Similar results were reported in other studies on blood donor motivation (Glynn et al., 2002; Randolph Steele et al., 2008). Another research on blood donors motives has indicated that motivation changes from an external factor to an internal factor as donations are repeated (Pilliavin & Callero, 1991). Educated blood donors also had a higher level of altruistic motivational factor as compared to illiterate donors; similar results being reported in other studies (Glynn et al., 2002; London & Hemphill, 1965). Altruistic behaviour varied greatly by age with donors in the 26 to 45-year-old range having the highest percentage. On the contrary other studies show that older donors have higher scores of altruistic motivation (Randolph Steele et al., 2008). In our study, 50% of the older donors (>45 years) stated that improvement in their own health was the main motivator. There may be a psychological impact in older donors who have a sense of improvement in their general health. In this study, improvement of one s health was an influential factor in deciding to donate blood among 38 6% of the donors. In the REDS study (Glynn et al., 2006), 26% of first-time donors and 31% of repeat donors claimed that good for one s health was either an important or a very important factor in their decision to donate blood. Although it is good that blood donors have a good perception of blood donation, considering blood donation as a means of reduction in cholesterol level, treatment of acne and so on has no sound scientific basis. It is possible that some of them are well aware that blood donation is important for patients; Therefore, they continue to donate blood regularly. Pennings (2005) believed that people who donate for their own health cannot be considered as purely altruistic donors because they have a self-serving goal. On the other hand Glynn et al. (2003) reported that donors who would be encouraged by improving their health had similar unreported deferrable risk levels in comparison with donors who were not encouraged. The slogan good for one s health was widely used at one time in this country, but its use has been put to an end recently. It seems that there is a need to evaluate this subject furthermore. Religious belief was the main factor to donate blood in 11 4% of respondent donors. Some people vow with

5 Blood donors motivations 251 God that if their wishes come true they will donate blood. They prefer to make their blood donation at special times of the year such as Muharram. Thus, blood donation significantly increases during these religious months. Blood donation increased more than 22% in Muharram 2007 in comparison with the mean of monthly donations in that same year (Maghsudlu et al., 2009). Screen health tests represented a main motivational factor in 3 7% of blood donors. Whether they were seeking an HIV screen test after a high-risk behaviour or control of blood pressure and Hgb level is unknown. Nonetheless, 37% of them were deferred from blood donation in the donor selection process, suggesting that they were unfit to donate blood in the first place. Glynn et al. (2002) reported that 2 4% of donors donated primarily to be tested for an infectious agent. In this study, obtaining a blood card was the main motivation in 2% of donors. In Iran, a blood card with his/her ABO-Rh blood group is sent to the donor after each donation. If results of viral screen test are negative, the donor is invited to donate blood again and if the test results are positive, he/she is invited to perform additional tests. In the past when a portion of blood was donated by replacement donors, the issued card was used as an insurance card. Now, with the establishment of 100% voluntary blood donations, there is no need to present a card at the time of blood transfusion. It is not known whether these donors are still unaware of the termination of the replacement system or that they simply have a sense of pride in having such a card. This study has several strengths. All the questionnaires were completed by physicians rather than by blood donors; therefore, the data collected were more reliable. The difference in method must be considered when comparing the results with other studies. Another positive point is the large sample size that increases the precision of the results. Finally, this study was an evaluation of motivations in blood donors nationwide. Several studies have been carried out on blood donor motivation. It is clear that limitations exist, which may influence the final results and conclusions. Some of these limitations have also been mentioned in other studies. First, the motives mentioned in these studies are based on donors self-report who may be inclined to choose a motive which they perceive as a socially acceptable motive rather than their real reason to donate. Second, the respondents in these studies are only a certain number of sampled donors who may be also more likely have an altruistic idea as opposed to non-respondents leading to a potential underestimation of non-altruistic reasons (Glynn et al., 2002). Finally, the results depend on also how the questionnaire is designed and how it is administrated. In conclusion, this study has shown that altruistic and religious reasons are the main reason for donation by the majority of blood donors (51%). Most of them are female, regular and high-educated donors. Altruistic and religious messages can be emphasized in recruiting and retaining these groups. About half of blood donors were motivated by other motivational factors, the main factor being improvement of their health. Simultaneous evaluation of the results of the screening tests and the motivational factor could give more valuable information. As voluntary non-remunerated blood donor is defined without considering a motivational factor, one might consider a new term as internal motivated voluntary blood donors in accordance with their motivation and all blood centres effort to their improvement. ACKNOWLEDGMENTS We are grateful to the Blood Transfusion Research Center for providing the required budget for this project. The authors would also like to thank the managers and physicians of all the blood transfusion centres within the country for their cooperation throughout the study. Mahtab Maghsudlu designed the research study, analysed the data and wrote the manuscript. Soheila Nasizadeh contributed to the research and wrote the manuscript. CONFLICT OF INTEREST The authors have no competing interests. REFERENCES Badden, P. (1985) Donor motivation. In: Donor Room Policies and Procedures (eds Green, T.S. & Steckler, D.), American Association of Blood Banks, Arlington, Virginia. Choi, B.C. & Pak, A.W.P. (2005) A catalog of biases in questionnaires. Preventing Chronic Disease, 2, A13. Farrugia, A., Penrod, J. & Bult, J.M. (2010) Payment, compensation and replacement the ethics and motivation of blood and plasma donation. Vox Sanguinis, 99, Ford, G.T. & Wallace, E.L. (1975) Effects of donor recruitment methods on population responses. Transfusion, 15, Glynn, S.A., Kleinman, S.H., Schreiber, G.B. et al. (2002) Motivations to donate blood: demographic comparisons. Transfusion, 42, Glynn, S.A., Williams, A.E., Nass, C.C. et al. (2003) Attitudes toward blood donation incentives in United States: implications for donor recruitment. Transfusion, 43, 7 16.

6 252 M. Maghsudlu and S. Nasizadeh Glynn, S.A., Schreiber, G.B., Murphy, E.L. et al. (2006) Factors influencing the decision to donate: racial and ethnic comparisons. Transfusion, 46, Hupfer, M.E., Taylor, D.W. & Letwin, J.A. (2005) Understanding Canadian student motivations and beliefs about giving blood. Transfusion, 45, London, P. & Hemphill, B.M. (1965) The motivation of blood donors. Transfusion, 5, Maghsudlu, M.,Nasizadeh,S.,Abolghasemi, H. & Ahmadyar, Sh. (2009) Blood donation and donor recruitment in Iran from 1998 through 2007: ten years experience. Transfusion, 49, Maslow, A.H. (1943) A theory of human motivation. Psychological Review, 50, Misje, A.H., Bosnes, V., Gasdal, O. & Heier, H.E. (2005) Motivation, recruitment and retention of voluntary non-remunerated blood donors: a survey- based questionnaire study. Vox Sanguinis, 89, Nguyen, D.D., Devita, D.A., Hirschler, N.V. & Murphy, E.L. (2008) Blood donor satisfaction and intention of future donation. Transfusion, 48, Oswalt, R.M. (1977) A review of blood donor motivation and recruitment. Transfusion, 17, Pennings, G. (2005) Demanding pure motives for donation: the moral acceptability of blood donations by haemochromatosis patients. Journal of Medical Ethics, 31, Pilliavin, J.A. (1990) Why do they give the gift of life? A review of research on blood donors since Transfusion, 30, Pilliavin, J.A. & Callero, P.L. (eds). Giving Blood: The Development of an Altruistic Identity. The John Hopkins University Press, Baltimore, Maryland and London. Randolph Steele, W., Schreiber, G.B., Guiltinan, A. et al. (2008) The role of altruistic behavior, empathetic concern and social responsibility in blood donation behavior. Transfusion, 48, Royse, D. & Doochin, K.E. (1995) Multigallon blood donors: who are they? Transfusion, 35, WHO. (2009) Blood donation rates per population. URL factsheets/donations-per1000-population pdf (Accessed 30/1/10).

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