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Blood donors and factors impacting

the blood donation decision
Theresa Gillespie

Transfusion Medicine Reviews

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 Blood Donors and Factors Impacting the Blood
D o n a t i o n Decision
Theresa W. Gillespie and Christopher D. Hillyer

The aging of the US population and the evidence that ror the donor pool to assist in targeted recruitment or if
only about 5% of individuals in the United States donate targeted recruitment actually leads to the reported de-
blood each year raise concerns about the assurance of mographics. Few recent studies of donor motivation
an adequate, safe supply of blood in the future. Blood have been published. Modern sources of positive and
donation decision making has been investigated world- negative motivation are worth exploring through scien-
wide for decades to understand the process better to tifically sound investigations involving representative
increase donation efficiency, safety, retention, collection cohorts using multifactorial approaches. Strategies that
numbers, and diversity of the donor pool. This review focus on retaining return donors and transforming first-
focuses on the characteristics of allogeneic blood do- time donors into repeaters would be beneficial. Investi-
nors, the motivational sources in donor decision mak- gations are needed also to assess research questions
ing, and the research concepts and techniques used to and to develop well-designed interventions to test hy-
examine these factors. Some historic studies consid- potheses and to produce generalizable findings applica-
ered pivotal, as well as more recent surveys, may not be ble to future donor decision making.
pertinent to or representative of the current national Copyright 2002, Elsevier Science (USA). All rights re-
donor pool. Interpretation of data related to donor char- served.
acteristics should examine whether demographics mir-

"NIQUE AMONG the armamentarium of babesia, trypanosomes, or prions) will have an

U widespread medical interventions, the avail-
ability of blood transfusion depends totally on a
additive effect on donor loss, with new restrictions
for variant Creutzfeldt-Jacob disease (as of Sep-
volunteer donor base. With the aging of the US tember 2001) decreasing the available blood do-
population and the predicted doubling of the pro- nors by an estimated 7% to 11%.
portion that is over age 65 by the year 2030, the Thus, although data differ as to whether a sup-
assurance of an adequate, safe supply of blood in ply-utilization disequilibrium exists whether sup-
the future is an area of considerable concern. 1,2 ply has driven demand, or whether a significant
Although close to half of the general population increase in supply would lead to further changes in
has reported giving blood at some time, only about use, allogeneic blood donation has been investi-
5% of individuals in the United States donate gated worldwide for decades. The intention of
blood each year) Donor trends have fluctuated these studies has been to understand the process
over the past 30 years, 4 with a notable decline of better to increase donation efficiency, safety, reten-
9.3% in the rates of blood collection from 1989 to tion, and diversity of the donor pool, as well as the
1994. 5 Unpublished data (M. Sullivan, oral com- number of new and total donations collected. It is
munication, August 2001) suggests that this trend known that efforts at recruitment of an expanded,
may not be continuing. Still, the number / of first- consistent donor pool have not been widely suc-
time donors in some regions of the country has cessful, and many centers have reported declines in
diminished significantly, 6 with overall reductions new donors despite significant growth in program
reported as close to 7% in the 1990s. Reduced funding for recruiting such donors. 9 Finally, it ap-
collection rates, in part representing the aging do-
nor pool and a decrease in the number of eligible
donors because of enhanced screening for transfu- From the Winship Cancer Institute and the Department of
sion-transmitted diseases, have resulted in an esti- Pathology and Laboratory Medicine, Emory University, At-
lanta, GA.
mated loss of approximately one-half million do- Supported in part by a grant from the National Blood Foun-
nors per year. v With recent data reporting fewer dation.
collections concomitantly with greater blood use, Address reprint requests to Theresa W. Gillespie, PhD, Win-
significant deficits in the blood supply are pro- ship Cancer Institute, Ernory University, 1365B Clifton Road,
NE, Atlanta, GA 30322.
jected for the near future, s Furthermore, required
Copyright 2002, Elsevier Science (USA). All rights reserved.
or voluntary restrictions on donors that relate to 0887- 7963/02/1602-0004535. 00/0
potential or known emerging infectious agents (eg, doi: l O.1053/tmrv.2002.31461

Transfusion Medicine Reviews, Vol 16, No 2 (April), 2002: pp 115-130 115

116 GILLESPIE AND HILLYER

pears that in general the vast majority of donors are nors and their decision making was conducted by
repeat donors who represent a small but committed Drake and colleagues ~ as part of a 5-year, Na-
group of individuals responsible for donating most tional Institute of Health-funded project of blood
of the blood in the United States and other coun- banking in the United States. l 1 These data from the
tries. This review will focus on characteristics per- 1970s revealed that the average donor was a mid-
tinent to allogeneic blood donors, motivational dle-aged white man, the most preferred site to give
sources in donor decision making, and research blood was a local hospital, and the majority of
concepts and techniques used to examine these individuals surveyed opposed paid donations. Os-
factors. walt's 1977 review 12 of the blood donor literature
described the "typical" donor as a white man rep-
CHARACTERISTICS OF ALLOGENEIC BLOOD resenting an organized group who tended to be a
DONORS repeat donor and who gave at a mobile unit in the
General Demographic and Personal community in which he resided. More recent data
Characteristics profile donors as married ~3 with 1 or more children
Theoretically, if donors can be profiled in terms and who often have a "rarer" blood type than
of their personal characteristics, then potentially nondonors.14,15
their behavior can be predicted and individuals
selected who are more likely to become or remain Gender
as donors. 1~ A variety of donor characteristics re- Although most donors were reported as being
ported in the literature are compiled in Table 1. men in the 1970s and 1980S, 12,16 increases in the
A comprehensive study investigating blood do- number of women donors were described in the

Table 1. Donor Characteristics

Donor Characteristics Reference (% Cited, Specifics of Variable)

General 18 (40%-50% general population at 1 point)

3 (4%-6% US population/yr, 8%-9% of eligible population)
14 (male, married, have children, higher education, rarer blood type)
Gender 13 (80% men)
12 (majority men)
50 (47%-64% women, mean - 54%, increase trend in 1990s)
15 (increased drop out among women after 4-8 donations)
Age 13 (28%, ages 20-29; 29%, ages 30-39; 25%, ages 40-49; 17%, ages 50-59)
18, 17 (mean = 33-38)
26 (mean = 38)
Race 13 (10% nonwhite)
19 (74% white, first-time donor)
Married 13 (57%)
30 (62%)
Educational level 19 (41% --- high school, 28% graduated college, 28% > college)
First-time donors 13 (19% total)
19 (52% men, 74% white, age: 28% -< 19 yr, 27% - 20-29 yr, 22% = 30-39 yr, 14% = 40-49 yr, 8% ->
50 yr)
50 (58% women)
6 (64% < 35 yr, 52% men, 88% US born, 32% > college education)
24 (dropout rate: 89% women, 63% men)
Repeat donors 15 (78%-91% of all current donors, women have major dropout rate after 4-8 donations)
31 (81%)
19 (43% = Rh negative, 43% return rate if > 50 yr)
9 (become repeater if return within 2 yr of first time, % return increases with age, and no. of previous
donations)
19 (highest repeat rate if return ~< 6 mos after first donation)
Multigallon donors 26 (mean age = 52 yr, mainly white, male, college grad)
50 (30% women)
Elderly donors 23 (mean age = 68 yr, 91.4% white, 6% Hispanic, most married, well educated with higher education)
BLOOD DONATION DECISION 117

1990s. In 1 study, women comprised 47% to 64% setting was a man, either a student or member of
of all donors, representing an average of 54%. A the military, and had higher levels of knowledge
recent evaluation of over 900,000 first-time donors about blood donation and needs for blood. 22
showed that women constituted 47.6% of this co-
hort, 6 a substantial increase in proportion of the Elderly Donors
donor base from 2 or 3 decades earlier. In anticipating the aging of the US population,
Simon and associates 23 conducted a randomized,
Age controlled trial of routine blood donation in elderly
Trends in donor age vary with the populations people over 63 years of age. A description of the
assessed and the types of donors represented. In 244 elderly donors characterized them as being
1965, 47% of all donors were 20 to 39 years old; 13 well educated, married, white, and "somewhat af-
in 1975, the average age was 33 to 38 years. L7,~8 fluent." These older individuals, although they
This age range remained consistent through the showed greater incidence of comorbidities and
1990s, with 63.6% of all first-time donors for the chronic ailments than younger donors, experienced
period of 1991 to 1996 reported as being less than no higher rates of negative reactions to blood do-
35 years old. 6 nation. Although the health histories of elderly
volunteers might have been a source of initial
Race and Place of Birth concern, the investigators advised that "if thor-
Although only 10% of the donor pool was re- oughly reviewed, the previous and current medical
ported as nonwhite in 1965,13 that number had conditions of the elderly will be found not to
grown to 26% for the period of 1991 to 199579 disqualify them for blood donation. ''23 Donation by
Results of a 1991 to 1996 survey of 5 major donor the elderly in this study was concluded as being
centers participating in the Retrovirus Epidemiol- both safe and practical and may represent an un-
ogy Donor Study (REDS) indicated significant tapped resource for recruitment or retention.
changes in the race and ethnicity of first-time do-
nors, with decreases in the number of white donors First-Time Donors
in all regions and increases in minority donors, The need for recruitment of new donors to re-
particularly Hispanic. 6 Wu and colleagues 6 pre- place other donors who have become ineligible or
dicted that by 2005 Hispanics will outnumber other dropped out of the donor pool, as well as to build
ethnic groups as the largest minority donor constit- the blood supply to prevent shortfalls, represents
uency in the country. In their study, the percent of an important focus of blood centers. About 19% of
non-US-born donors overall was 12%, reflecting the donor base are those giving for the first time, ~3
an increase in this group in several regions of the with the overall dropout rate cited as 89% for
country. women and 63% for men. 24 Wu and others from
the national REDS group 6 described first-time do-
Education and Socioeconomic Status nors during 1991 to 1996 as mostly white, and US
Recent data showed that approximately one born; 52% were men. In this cohort, 77% were less
third of first-time donors had a college or graduate than 39 years old, including 28% who were 19
degree, 6 with 45% of repeat donors having at least years or less, reflecting targeted first-time donors
a college education. 19 Higher educational status from high school and college populations. The
correlated with income level of donors, which was total number of first-time donors was reported at
reported by a survey of 15 blood centers to be the 5 REDS centers as being decreased by 6.7%
about 30% higher than the average income of during this time period, which raised the question
nondonors. 2o of national apathy toward blood donation. How-
Similar characteristics have been identified for ever, specific regions (eg, Southern California and
donors in countries other than the United States. 2~ Oklahoma) experienced a significant increase
In a 1994 study of over 800 randomly selected (60%) in new donors. Such descriptive data do not
donors in Greece between 18 and 65 years of age, clarify the underlying reasons for these statistics,
stepwise multiple regression analysis revealed that although certain centers had explicitly targeted mi-
blood donation correlated with gender, occupation, nority recruitment as part of their donor cam-
and knowledge level. The "standard" donor in this paigns.
118 GILLESPIE AND HILLYER

Return Donors smaller proportions reported for donors 30 to 44

years old (80% return) and 15 to 29 years old (70%
Repeat donors comprise the majority of the do-
return rate). Return behavior correlated directly
nor pool, representing a range of 78% to 91% of all
with the number of previous donations, ranging
donors.13.15 This proportion of the donor pool has
from a 95.7% return rate for 30 or more prior
changed little over time because the blood supply
donations to 57% return rate if the individual had
has been "heavily dependent upon a core of com-
given only 1 previous donation.
mitted, regular donors ''15 for the past 30 years or
Piliavin 15 classified return donors into 2 catego-
more. Review of the literature indicates that al-
ries: (1) those who had given 1 to 3 times and those
though characteristics and motivation of first-time
who had donated 4 or more times. Facilitating the
donors are important for guiding recruitment strat-
transition of repeat donors to the latter classifica-
egies, their high drop-out rates underscore the need
tion was found to be critical in generating long-
to address factors related to return donors. Recruit-
term repeat donors. Thus, interventions designed to
ment and retention of repeat donors lead to a safer
encourage donors to continue through the fourth
blood supply with lower incidence of transfusion-
donation could have a significant effect on main-
transmitted viral diseases, create a donor pool that
taining the overall donor pool.
tends to be more responsive to donation requests,
In studies performed by using the REDS data,
and facilitate ongoing recruitment of new and Ownby and colleagues 19 evaluated 879,816 first-
,lapsed donors. 25,26
time donors from 1991 to 1995 for return behavior.
The importance of return donors was under- Factors predicting a higher likelihood of repeat
scored in a quantitative analysis of donations in blood donation included (1) shorter time interval (6
Australia. 9 The effect on total donations caused by months or less) between the first and second do-
a slight decrease in overall return rates from 88% nation attempt (P < .0001); (2) increased age, with
to 85% at 2 years was shown as correctable either those 50 years or older showing a 43.3% return
by maintaining the return rate at 88.5% or by rate, whereas those less than 20 years old associ-
increasing the recruitment of new donors by 33%. ated with only a 33.3% return rate (P < .0001); (3)
Clearly, retention appears to be a far more efficient higher levels of education, with college or graduate
strategy in this population. Thus, defining the op- degrees associated with a 45% return rate com-
timal method for retaining donors who later return pared with those with some college (39%) and a
and give blood on multiple occasions represents a high school education or less (34%) (P < .0001);
worthwhile goal with long-term advantages and and (4) Rh-negative status, with a 43% return rate
has been the subject of intensive study. 27 versus Rh-positive donors who showed a 37% re-
Certain factors have been reported to have sig- turn rate (P < .0001). By using multiple regression
nificance in predicting the return behavior of do- analysis, age was found to be a strong predictor of
nors. James and Matthews 28,~9 analyzed blood do- early return and higher frequency of donation.
nor return behavior by using survival curves. The However, the investigators acknowledged that the
time from the initial donation until subsequent youngest age group was likely more mobile and
donation was termed the donation cycle to develop may actually have repeated donations at other
a framework to measure and analyze return behav- blood centers, but their study was unable to capture
ior as interval data. Relative risks were shown to be such data. Importantly, the average time from the
time dependent, with the likelihood of a second initial donation to the return attempt was the most
attempt at donation diminishing over time since the significant factor in predicting later returns, with
initial donation. Similar donation patterns were the number of donations inversely related to the
reported by Whyte and colleagues 9 in Australia, length of time between the first and second dona-
where 8.9% of the population (1.6 million people) tions. The highest number of donations was ob-
gave 2.4 million donations over a period of 34 served when 6 months or less elapsed between the
months, in this study, return behavior within 2 initial donation and subsequent attempts.
years predicted future patterns of donation and was
highly related to age and the number of earlier Return Behavior of "Safe" Donors
donations: for donors 45 to 69 years old, over 90% Thomson et al3o surveyed over 50,000 randomly
returned within 2 years to donate again; with selected blood donors considered "safe" after test-
BLOOD DONATION DECISION 119

ing of donated units to determine these donors' viewed their long-term donation as a proud accom-
intent to donate again during the next 12 months. plishment (51% vs 32%, P < .001), few donors in
In evaluating their intentions about future dona- either group reported feeling that they had received
tions, only 3.4% of this cohort stated they would be support or recognition for their contributions.
unlikely to donate again in the next year. Donors About 20% of these large-volume donors had a
indicating a reduced intent toward repeat donations prior "bad experience" donating blood but per-
tended to be first-time donors of minority or ethnic sisted in giving blood on a continued basis, show-
background, with lower levels of education, who ing their ability to overcome obstacles commonly
had a poor assessment of their treatment by the encountered in the blood donation process. No
collection center, and/or had a negative reaction or significant differences were noted in the stated
"bad experience" during the donation process. Al- reasons why multigallon donors gave blood com-
though intention is central to decision making, pared with the random donors except that the
statements of intent do not always accurately pre- multigallon donors reported a greater tendency to
dict behavior. Although this study examined anon- participate in humanitarian volunteer efforts com-
ymous survey results of intention to return, no pared with other groups (35% vs 24%; P < .05).
authentic return behavior was recorded; however, a However, in analyzing the study's findings, the
97% actual return rate would be highly unlikely low response rate (2t%) to the mail survey by the
based on other studies in the literature. These re- random donor group should be noted because it
sponses also highlight the bias encountered in eval- raises the question of the representative nature of
uating donor questionnaires because respondents the sample.
may exhibit a tendency to provide answers they Despite the myriad studies and intensive efforts
think they are expected to give or believe the over time to profile donor characteristics, the exact
investigators wish to receive rather than supplying usefulness of demographic data should be inter-
a more realistic perspective. preted cautiously. Demographics likely are not
data causally related to donation. Most surveys of
Multigallon Donors demographic characteristics draw from limited,
Among the group of return donors, most coveted nonrandom sampling often using flawed study de-
are those individuals who have given repeated do- sign and/or instruments. The theoretic basis for
nations equal to 1 or more gallons. Royse and many donor studies remains vague or undeveloped.
Doochin26 surveyed by mail 500 multigallon do- Centers may target certain groups with campaigns
nors who had given at least 5 gallons of blood directed toward specific characteristics (eg, Rh-
(median donation, 64 units) and compared their negative blood type), or study samples may mirror
responses to those from another 500 random do- recruitment techniques and sites. The success of
nors who had not donated blood as frequently cold calls to potential donors and subsequent donor
(median donation, 9.5 units). The multigallon do- recruitment may be based o n demographic-tar-
nors were characterized as white male college geted calling in that "demographic differences be-
graduates who had higher levels of awareness of tween donors and nondonors may be perpetuated
the need for blood donation. The mean age of these through a self-fulfilling prophecy, m5 Donor char-
donors was significantly older at 52 years com- acteristics may also simply be a reflection of the
pared with the 38 years of the random donors. No more practical aspects of blood donation. For ex-
significant differences between the groups were ample, the greater return rates for individuals with
reported for having had close friends or family higher education may actually relate to increased
members who were also donors or who had previ- socioeconomic status and the concept that these
ously been transfusion recipients or for overall donors may have more time available to give
attention to their own health habits and practices. blood.
However, multigallon donors tended to indicate a
deeper, more long-term psychological commit- POSITIVE MOTIVATORS
ment toward blood donation compared with the
random donor group, with a stronger desire to give Altruism
blood until they were very old (86% vs 66%, P < Oswalt's ~2 and Piliavin's and Callero's 15,18 re-
.00t). Although the multigallon donors more often views of 3 decades of literature on motivation and
120 GILLESPIE AND HILLYER

recruitment of donors and nondonors reported that would be motivated to repeat donation if medical
primary motivation to donate blood consistently testing was a benefit. The elimination of assurance
had been determined to be altruism, defined as and credit programs at most centers has modified
"prosocial behavior that has no obvious benefit for this reason as a source of general motivation, js
the respondent but is beneficial to the recipient. ''31 Receipt of items of small or limited value for
Individual studies have also attributed donor be- blood donation was identified as a positive moti-
havior primarily to altruistic motives. 13,32,33 vator to 20% o f those surveyed by Sanchez and
The exact role of altruism in the blood donation colleagues, z~ Incentives had a greater effect on
decision-making process, however, has been ques- first-time donors and those in younger age groups.
tioned. ~4,34 In some cases, altruism and social re-
Although incentives of limited value were viewed
sponsibility were among the least significant mo-
as both safe and potentially effective, the offering
tivations identified as reasons for blood donation. 35
of cash was found to entice donors who were 60%
Behavioral catalysts other than altruism have been
more likely to be at risk for donation of transfu-
proposed in that (1) donors may actually derive
sion-transmitted infectious diseases (P = .03). 4o
direct benefit from giving blood, including a boost
to their self-esteem14.33.36.37; (2) individual donors Donors who were motivated by free tickets to
events as a result of their donation were also more
are likely motivated by multiple factors simulta-
neously; 3~ (3) decision making and behavior en- likely to represent an increased risk (odds ratio,
compass cognitive, affective, and psychological [OR], 1.5) o f transfusion-related infection, as were
components on many levels; 11 (4) altruism itself is respondents who favored extra time off work as an
a complex, multidimensional concept for which the incentive (OR, 1.2). In an earlier study comparing
empirical basis for studying behavior is difficult to the motivations of donors with nondonors, 80% of
establish; 3~ and (5) donors questioned about their donors indicated money would not serve as an
motivation m a y be unaware, unable, or unwilling incentive to them. 41
to express their underlying reasons with great ac- Countries outside the United States have modi-
curacy. 3. In many reported studies, important dif- fied their voluntary donor system and implemented
ferences likely exist between what the subjects methods whereby donors are paid. Zeiler and
stated and what their actual reasons were for giving Kretschmer 42 questioned over 1100 German blood
blood, raising the question of the overall validity o f donors about their views toward reimbursement for
these studies. As for demographic data, one must donation: 77% responded they would no longer
be careful not to automatically interpret the stated want to donate blood if reimbursement ceased en-
motivators as having a causal relationship with the tirely, although 78% were willing to accept a bank
behavioral outcomes. Many reasons cited as moti- transfer rather than immediate cash payment as
vational sources may simply be a means of ratio- remuneration. Alternative payments to cash, such
nalization, and such concepts are generally multi-
as in-kind tickets or coupons, met with the ap-
factorial in nature.
proval of only 27% of this cohort, but 37% indi-
cated they would still be willing to donate blood if
Incentives the in-kind payments were the only reimbursement
received. Greek subjects specified 3 types of in-
The role of incentives has been investigated as a
centives that most influenced their decision to give
potential key component of donor motivation. 39
blood: (1) health incentives for the donor; (2)
Earlier studies of blood donors revealed that 50%
of donors were motivated by the assurance of guar- structural and organizational factors, including do-
anteed blood replacement for family members, and nor education and management of blood center
10% gave blood to cover their own potential needs facilities; and (3) social or economic incentives. 22
in the future, j3 In a 1995 mail survey of over 7400 Incentives may actually serve to impede the blood
blood donors in the REDS cohort, 4~ subjects were donor decision. In 1 study, high incentives were
asked about their attraction to different incentives associated with decreased number of donations,
as sources of motivation to continue giving blood. whereas high levels of positive intrinsic motivation
Of this group, 58% indicated they would return if coupled with low rewards were found to result in
offered blood credits, whereas 46% stated they the highest number of donations overall. 43
BLOOD DONATION DECISION 121

P?'essbtre current donors, 71% of lapsed donors, and 40% of

nondonors agreed. Cold calls targeted to nondonor
Sources of external pressure used to motivate
households that fit a precise demographic profile of
individuals to give blood may take numerous
potential donors yielded a 20% agreement rate
forms including role models; personal requests;
among individuals contacted, but only 14% of
and contacts with others who may exert pressure in
those who agreed actually showed up to donate.
the form of phone calls, letters, or face-to-face
Because many of these nondonors also brought in
communication. 44 One theory contends that blood
1 or more individuals to give at the same time, the
donors actually have a lower sense of self-esteem
true response rate to the contacts was closer to
and give blood in an attempt to raise their self- 30%. 48 A review of positive motivators is included
concept. If correct, this could mean that donors are in Table 2.
naturally more vulnerable to pressure to comply
with others' stated requests. ~ 5 0 b o r n e and Brad-
ley 33 reported that over half (56%) of all donors NEGATIVE MOTIVATORS
gave blood only because of personal pressure from Fear and Anxiety
others. In Drake et al's study 11 conducted in the Various fears have been described by both non-
1970s, only 19% of eligible nondonors reported donors and donors as having a negative influence
having been directly asked to donate compared on the decision to donate blood, including fear of
with 38% of first-time donors and 54% of those needles, sight of blood, pain or discomfort, and
repeating blood donation. The primary reason being told they are not eligible to give blood.
identified as to why nondonors did not give was Donors may experience these fears but make the
"no one asked me personally." decision to give blood despite their concerns. 49
Personal contact by recruiters and other donors Whether such fears are legitimate or serve mainly
can be very powerful motivators, with face-to-face as rationalization to avoid giving blood remains
contact reported as 4 times more effective than a unclear. 12 General fears about the donation process
phone call, especially for those considering donat- have been alluded to as a primary source of nega-
ing for the first time. 15,45,46 Friends and relatives tive motivation for at least one quarter to one third
who are already donors were cited by 75% of new of nondonors, 13,41,44 with specific fear of needles
donors as positive motivational factors in London identified by 15% to 27% of those deciding not to
and Hemphill's reviewJ 3 whereas contact with or give blood. ~3,41 First-time donors fear pain more
modeling by other donors was identified as the often than those who have previously give
primary reason for giving blood by 45% of Aus- blood 24,32 along with a greater fear of the "un-
tralian first-time donors. In a high social pressure known." Likewise, anxiety may be generally ex-
situation designated as "intense collection environ- aggerated initially, with a range of 19% to 37% of
ment", in which potential donors are heavily re- donors reporting being nervous before the donation
cruited, donor yield can be impressive. 11 These process. However, anxiety was observed to de-
crease as the number of donations increased and
recruitment efforts forced individuals to state their
the donor became more accustomed to the experi-
decision as to whether they will donate blood or
ence.50
not, with the majority submitting to the pressure
and agreeing to give. Those who resist the recruit-
ment pressure must do so proactively: in an intense Short-Term Donor Deferral
collection environment, 74% of nondonors con- Volunteer blood donors may not return for sub-
sciously make the decision not to give blood, sequent donations because of temporary deferral,
whereas in the general population only 20% of including low hematocrit, sore throat, fever, or use
those who do not donate ever make such a delib- of disallowed medication within established time
erate decision. periods before the donation point. Anticipation of
Even cold contacts can be useful in recruitment. temporary or permanent deferral has been fre-
When Hayes et a147 contacted individuals to ask quently cited as a reason to avoid donation. 51 Pili-
them for permission to be put on a list of potential avin 52 surveyed over 1200 donors to determine the
donors to call for future blood drives, 85% of role of temporary deferral on later donations. First-
122 GILLESPIE AND HILLYER

Table 2, Sources of Positive Motivation for Blood Donation

Positive Motivator Reference (% Cited, Specific Concept)

Altruism 13, 14, 31, 33, 34, 44 (also duty)
Community 26 (35%), 75, 76
Incentives 39, 41 (87% not motivated by money)
40 {20% want items of limited value; 46%-58% want medical testing)
Personal benefit 44 (28% health)
33 (personal fulfillment)
General pressure to donate 44, 26 (11% multigallon donors);
11 (higher yield in "intense collection environments")
15 (if lower self-esteem especially vulnerable to pressure as motivator)
Personal request 33 (56% donate only because of peer pressure)
11 (19% nondonors asked to give vs 38% first-time donors vs 54% repeat donors)
17 (38% first-time donors give with a friend)
Personal contact 45, 46 (for 1st time donor, face-to-face by recruiter more effective than phone contact)
15 (face-to-face most effective for recruitment)
Request from other donors 13 (75% donors had family/friends already as donors)
2 (45% donors cited contact with other donors as main reason why give blood)
Awareness 11 (#1 reason cited why gave blood)
58 (27% current/lapsed donors-primary motivator)
Self-Esteem 36, 37, 33, 14 (decreased self-esteem in donor's vs nondonors)
13 (donors experience increased self-esteem after donation)
Don't know why they give 38, 32 (2nd most common reason cited)

time donors who had received a short-term tempo- In Noonan et al's 54 study of 187 donors with
rary deferral (STTD) and those who had no donor STTD, only 11% returned despite phone calls and
deferral (NDD) were compared for later donor letters in follow-up; however, none of the first-time
behavior. In a 6-month follow-up period, only donors (0/64) with STTD returned. In a study 55
2.8% of the STTD first-time donors returned for a designed to promote retention of deferred donors,
second donation versus 27.3% of those donors who considerable effort to contact donors with STTD
were not deferred. The investigator proposed that within 3 to 4 weeks after their deferral resulted in
first-time donors interpreted temporary deferral as a doubling of the return rate of STTD donors from
a psychological reason justifying why they should 24% to 47% within the first 6 months after deferral.
not repeat blood donation. All of these studies underscore the importance of
Halperin et al 5~ found similar results in a longi- the potential effects of short-term deferral on sub-
tudinal study of donor behavior in which donors sequent donor behavior and emphasize the central
with STTD were matched with donors with NDD goal of blood centers to keep donors in the pool.
by sex, age, and date of donation and followed for
over 4 years. Return rate and total number of Permanent Deferral and Medical Reaction
donations were compared between the 2 groups. Close to 60% of potential donors claim concerns
Those individuals with NDD were 29% more about possible chances of being medically disqual-
likely than the STTD donors to return for further ified as a donor or physical reactions to blood
donation (80% vs 62%, P < .001). In terms of total donation as sufficient reasons not to give blood. 24,4~
units of blood donated, donors with NDD gave But, as for other fears, the apprehension regarding
81% more blood (13798 units vs 7615 units) and deferral or reactions may simply serve as justifica-
averaged 1.45 units/year/donor versus 1.03 units/ tion to avoid giving blood. 12 Approximately 10%
year/donor for those with STTD. The reason for of individuals who attempt donation experience
deferral also played a role, with return rate by some form of adverse reaction (eg, syncope, 2%-
deferral code ranging from 11% to 34% and dif- 9%) ~s often resulting in a negative attitude that
ferences measured in units of blood donated by may limit or delay return donations. ~8 Ranasinghe
deferral code ranging from 43% to 202%. and Harrison 56 investigated 1 specific type of "bad
Short-term temporary deferrals can have acutely experience" as viewed by blood donors, evaluating
negative effects on first-time donors in particular. the effects of significant bruising on subsequent
BLOOD DONATION DECISION 123

donation behavior in the United Kingdom. No sig- for about 16% to 20% of nondonors as to why they
nificant difference was noted in repeat donations do not choose to give blood. 24,41 Oswalt 12, how-
between those donors who experienced bruising ever, hypothesized that this concept is misleading
during blood collection versus those donors who in that nondonors are rarely indifferent. Rather, the
did not sustain bruising. Adverse reactions were majority of individuals questioned about their will-
shown to have no effect on the return behavior of ingness to give blood appear to recognize the im-
multigallon donors? ~ Again, as for fear and anxi- portance of blood donation and state they would
ety, first-time donors were more susceptible to agree to give if the "correct conditions" were in
worries about and the negative effects of medical place. 2 The "correct conditions" may encompass
deferral and donor reactions. motivators, physical status, and aspects of the do-
nation process, which presumably do not meet the
Lack of Awareness standards of nondonors or do not continue to meet
Ignorance or being unaware of the need for the standards of lapsed donors. Only about 20% of
blood or other aspects of the donation process has eligible nondonors in the general population ac-
been consistently identified as a negative factor in tively decide not to give blood in the future; 11 yet,
potential donor decision making. 44,57 The lack of less than 10% of the eligible population actually
being specifically asked to give blood is the chief donates blood. 3 A more accurate reason why so
reason provided why nondonors failed to give 11 many potential donors decide not to pursue dona-
and may also explain poor return rates among the tion is likely inertia rather than apathy. 2
majority of donors. Analysis of 9000 current, A listing of common sources of negative moti-
lapsed, and nondonors in the United Kingdom de- vation is provided in Table 3.
termined that 27% of the current or lapsed donors
were primarily motivated by awareness of the need PROCESS MEASURES
for blood coupled with an understanding that indi-
vidual donors may personally need blood in the General Donation Experience
future. ~8 First-time donors may posses greater concerns
about discomfort and fear of the donation experi-
Apathy ence, whereas repeat donors tend to be more fo-
Defined often as "a state of indifference, lack of cused on the donation process and the blood center.
feeling," apathy has been cited as a major reason Repeat donors often perform a cost-benefit analy-

Table 3. Sources of Negative Motivation for Blood Donation

Negative Motivator Reference (% Cited, Specific Concept)
Fear (general) 12, 13, 44, 41
49 (both nondonors & donors have fears, emphasis on fears exaggerated).
41 (36%)
24 (23%)
11 (61%)
Fear of needle 41 (27%)
13 (15%)
Fear of pain 2, 32, 24, 13 (new donors more than repeats)
Fear of deferral 9, 52
Fear of medical disqualification 41 (60%)
24 (57%)
51 (frequently cited)
27 (may represent rationalization)
Anxiety-nervousness 44, 41 (37%)
13 (19%)
50 (decreases as number of donations increase)
Unaware/ignorant of need 44, 57, 60 (primary reason cited by minority students)
Never asked to give 11 (#1 reason by nondonors why don't give)
Apathy 41 (16%), 24 (16%), 12 (likely not real reason)
2 (more likely inertia vs apathy)
124 GILLESPIE AND HILLYER

sis based on their prior experiences and recalculate (6.2%-19% attrition). These findings were espe-
whether it is "worthwhile" to donate again. 15 Neg- cially relevant to first-time donors, for whom attri-
ative donation experiences account for about 6% to tion rates among those who reported negative do-
19% attrition for all donors and 20% to 41% of the nation experiences ranged from 19.7% to 40.9%.
dropout rate for first-time donors? 0 In comparison, first-time donors who provided
positive ratings about the donation process showed
Convenience significantly lower attrition rates (10.7 %- 14.1%, P
General convenience of the process is rated as -< .0001). In this study, the donor's view of treat-
very important by most donors, with "inconve- ment by the center staff (OR, 3.0) and the level of
nience" identified as a primary barrier to donation physical well-being during and after the donation
by 13% to 19% of lapsed or nondonors. 13,24,41,5v process (OR, 6.0) were the 2 factors with the
Overall, convenience or lack thereof has been strongest predictive value for future donation (P --<
shown to be a major factor separating the high- .001). Waiting time was also an important predic-
volume donor from those who give less often and tor: donation time of 2 hours or less was associated
was cited as the second most important reason why with increased donor retention (OR --> 1.5, P --<
nondonors do not give blood. ~j Perception of con- 0.039). However, in this study, analysis of return
venience of the donation process varies with do- behavior was based on stated intent to return rather
nation frequency: 54% of nondonors thought the than actual documented return rates.
~ process was convenient compared with A review of aspects of the blood donation pro-
60% of those giving blood for the first through cess that may affect decision making and behavior
third times and 72% of donors who had previously is included in Table 4.
given blood 4 or more times.lJ These data do not Because blood donation by minorities tends to
clarify whether the more frequent donors simply be significantly reduced compared with whites,
accepted any inconvenience because they were Oswalt and Gordon ~~ investigated the motivation
more accustomed, or more committed, to the pro- of minority students to determine the relation to
cess or if the findings reflect heightened concerns donation behavior. Of 120 minority college stu-
about inconvenience by individuals who rarely or dents surveyed, 33% had donated blood, for whom
ever gave blood based on inexperience, misinfor- the primary motivational factor was cited as altru-
mation, or rationalization. The site where donation ism. Similar negative motivators, including fear,
takes place is considered an important deterrent to decreased awareness of the need to give, and per-
donation if it is specifically perceived as inconve- ceived lack of time, were identified for minority
nient. 11,15 Thus, mobile units, worksite- or school- subjects as those reported for whites. The investi-
based drives, and opportunities for donation close gators concluded that educational and socioeco-
to population centers are essential to donor recruit- nomic factors, rather than motivational, were the
ment and retention. 59 prime reasons for lower rates of blood donation
among minorities as compared with whites.
Center Staff"
Treatment of donors by the staff who provide THEORETIC MODELS AND METHODOLOGIES
the technical and administrative oversight of blood IN BLOOD DONATION STUDIES
donation is a key factor in the donation decision. In
Thomson et al's 3~ study of "safe" donors, most Social Capital and Public Goods
donors rated their overall donation experience as Interpretation and application of some of the
good to excellent (96%), with high levels of satis- findings published in the literature may be facili-
faction with their treatment (98%) and the skill tated through attention to theoretic models and an
level of the technical staff (96.3%). For donors understanding of the methodologic limitations in
who reported a very positive donation experience, specific cases. A widespread theory used to explain
the attrition rate was quite low (2.3%-3.0%). How- donor behavior draws from the concepts of social
ever, donors who gave a fair to poor rating of the capital and public goods. In keeping with the pref-
waiting period (13.8%) or physical well-being dur- erence toward a voluntary, public, nonprofit, low-
ing and/or after the donation process (6.3%) were cost blood system, yon Schubert 61 applied the the-
less likely to return for subsequent donations ory of public goods to blood donation to explain
BLOOD DONATION DECISION 125

Table 4. Process Measures that Influence Blood Donation

Donation Process Measure Reference (% Cited, Specific Concept)

General donation process 30 (6%-19% attrition for all donors, 20%-41% attrition for firstAime donors
due to negative donation experience)
30 (first-timers more concerned about discomfort, repeat donors more
focused on donation process)
General convenience of process 57, 41 (19% inconvenient), 24 (13% inconvenient)
13 (13% perceived process as inconvenient);
11 (54% nondonors vs 60% 1st through 3rd-time donors vs 72% > 4th time
donors perceive process as convenient)
11 (#2 reason after "never been asked" cited by nondonors as
w h y don't give, major factor to separate frequent vs less frequent donors
59 (61%-91% want weekday schedule not weekend)
Convenience of site 11, 15 (major deterrent if inconvenient)
59 (mobile units, employment sites important)
Treatment by center staff 9, 30 (OR = 3.0 perception of staff treatment, strongest predictor of return
donor behavior, 2%-3% attrition if good-excellent treatment by staff)
Waiting time 15 (10% donors complain of long wait)
56 (perceived wait, not actual waiting time, especially during first donation,
most predictive of later repeat donation)
Total time for process 59 (75% want < 90 min for entire donation process, including travel time)
30 (7% projected attrition if previous donation took > 2 hr)
15 (perception of wait more important than actual time waited)
Short-term temporary deferral (STTD) 9, 52 (2.8% return after STTD vs 27% if not deferred)
53 (62% return after STTD vs 80% if no deferral, nondeferred give 81%
more units blood over 4-yr period)
54 (11% return after intensive follow-up efforts but 0% of first-time donors
after STTD)
Questions for health history 30 (8% dropout rate if perceived as too personal)
Reaction during donation 15 (2%-9% experience syncope)
18 (10%-12% have bad experience, reduced return rates)
10 ("bad" experience has negative effect on first-time donors not on
multigallon donors)
56 (no effect on repeat donations after bruising)

Abbreviation: OR, odds ratio.

the altruistic motivations of donors. Donors show a Health Belief Model and Intended Behavior
lesser tendency to desire a "free ride ''5~ related to The aim of most studies of donor characteristics
public goods in general and a greater commitment
and motivations is to develop a profile that might
to responsible stewardship of social capital.
be used to predict donor behavior, thus promoting
Personal Norm and Attribution of Responsibility further blood donations. However, surveys have
generally focused on respondent attitudes, beliefs,
Other sociopsychological theories and approaches
and intents, without necessarily reflecting actual
to interpreting motivation and decision making in
blood donation have been cited. Personal norm behavior. The Health Belief Model 6~ incorporates
proposes that donors possess the feeling that they intent into its concept of knowledge, attitude, and
"ought" to give blood, whereas attribution of re- practice in that intent most frequently precedes
sponsibility to oneself suggests that individuals behavior. Promotion of intent may be important as
cannot simply make excuses for lack of action. 62 a first step in decision making toward sustained
Changes in motivation across the donor cycle may return behavior. Oswalt and colleagues 64 contacted
be explained by the attribution of responsibility to inactive donors in 3 ways to attempt to facilitate
oneself theory. The influence exerted by external repeat donations: group A, notified of dates when a
motivators, such as social pressure, decreases as blood mobile would be nearby; group B, notified of
the level of intrinsic motivation (eg, sense of duty blood mobile dates and requested to choose a time
or responsibility) increases. when they intended to donate blood; and group C,
126 GILLESPIE AND HILLYER

informed of upcoming drive through general pub- positive and negative forces and their interactive
licity only. Those individuals who were asked to roles is essential in designing successful and cost-
specify their intent (group B) showed higher rates effective interventions.
of donation than those informed by other means.
Reports of intention to return have varied
widely, from Piliavin and Callero's ~8 finding of Measurement Techniques
39% to 57% of donors who indicated they were Because attitudes are closely linked to affect,
certain to return to Thomson and associates whose cognition, and behavior, Breckler and Wiggins 66
survey found almost 97% of their cohort intended warned against simply using a bipolar scale to
to donate again within the next 12 months? ~ Ac- measure attitude. Instead, they recommended all
tual dropout rates among first-time donors are dimensions be measured simultaneously. In their
much higher (89% for women and 63% for men24); study of both donors and nondonors, implementa-
thus, intention may represent an unreliable surro-
tion of 3 new scales, in addition to an attitude scale
gate as a predictor of subsequent donor behavior.
measured on a continuum, showed affect to be
Opponent-Affective Process more strongly correlated with the number of prior
donations than cognition. Thus, how the donor felt
To aid in predicting donor behavior, Zillmer et
about donating blood was identified as the key
al 3~ tested 245 college students before blood dona-
tion and at 3 different time points after donation factor in the blood donation decision and subse-
was completed. Mood was measured by using the quent behavior, showing greater impact than what
mood adjective checklist, and anxiety was identi- the donor knew about the collection process and
fied as present at the highest levels before dona- need for blood donation.
tion, with positive feelings of elation elevated after Issues of interviewer bias and question threat
the donation experience. The investigators inter- were raised by Lightman 6v in a study of altruism in
preted these findings as indicative of an opponent- Canadian blood donors, which compared responses
affective process, which is similar to an addiction with identical questions asked by both personal
in which negative feelings are replaced by a sense interview and mail survey. Incongruities in re-
of exhilaration because of the specific action of sponses were shown to be caused by methodologic
blood donation, in line with this theory, first-time problems rather than representing actual differ-
donors, in particular, would need to be encouraged ences in the motivation, attitudes, and behavior
to overcome the initial anxiety and negative feel- reported by subjects.
ings to reach the point of elation postdonation. The approaches used to predict and present
trends in blood donation have also been questioned
Evaluation of Motivational Factors
in terms of techniques used in data collection and
Reports from studies of motivational factors interpretation. The delay between collecting dona-
need to be examined for how accurately they rep- tion rates and reporting these data can vary from 1
resent the complexity of reasons most donors show to 4 years or more, meaning projections of future
in deciding to give blood. Attitudes, motivation, trends may be based on outdated information 5,68,69
and behavior have frequently been organized and
and seldom on real-time data. Other aspects of the
measured along a 1-dimensional continuum rang-
blood donation system may also have significant
ing from absent/very low to very high. Such mea-
impact on trends, as shown by Whyte 9 who devel-
surements fail to take into account the competing
oped a logical predictive model of return behavior
elements, both positive and negative, that are in-
volved in decision making. Cacioppo and Gard- of blood donors in Australia. What appeared ini-
ner 65 suggest the use of a 2-dimensional grid to tially to be large shifts in the blood collection
evaluate attitudes that affect the blood donor deci- trends and projections, on further analysis were
sion. Although positive motivators such as altruism explained as small (2%-4%) decreases in donor
may account for some aspects of the decision- retention rates at 2 years. Had these donors actually
making process, negative deterrents including per- returned to collection centers at that point to repeat
sonal fears, time constraints, and lack of knowl- donation, the overall trends would have been un-
edge also impact behavior. Understanding both changed.
BLOOD DONATION DECISION 127

APPLICATION OF FINDINGS TO DESIGN through simple, practical approaches as well. As a

OF INTERVENTIONS mechanism to address the hypothesis that donors
Routinely, the study of donor characteristics and easily forget when they are eligible to give blood
motivation has been undertaken as a means to again, written reminders were sent to French do-
identify significant variables that affect the blood nors. 71 However, the frequency of mobile collec-
donation decision and other key components of the tion units to particular sites was also increased as a
second intervention to determine the effect of this
collection process. Frequently, studies report long
variable on donor return behavior. An increase in
lists of attributes that describe their sample. By
the frequency of blood donation was shown to be
using discriminate analysis technique, Burner04
secondary to the greater number of mobile unit
evaluated the results of 577 questionnaires com-
visits but was not related to reminders of upcoming
pleted by donors and nondonors in 1 city to attempt
donation due dates.
identification of the most relevant variables and the
Building on data drawn from the literature,
integration of characteristics into a meaningful
Gimble and colleagues v2 identified the issues of
model for both donors and nondonors. The com-
donor knowledge, donor defeixal, waiting time,
posite profile of donors in 1982 revealed some new
and convenience as being important for recruit-
variables not previously reported. A typical donor
ment and retention of blood donors. Twenty-four
was a family man, often possessing rarer blood
collection sites were paired with an equal number
types, with higher education but lower sense of
of other sites and randomly assigned as either
self-esteem, who was concerned about his health
experimental or control. Recruitment brochures ex-
and family and unwilling to take significant risks.
plaining eligibility to donate and criteria for tem-
Nondonors were described as having opposite
porary deferral, as well as other aspects of the
traits. The results of this study advise against de- collection process, were distributed to the 24 ex-
veloping interventions that are generically de- perimental sites 2 weeks in advance of the blood
signed to target both donors and nondonors. As an drive. Three drives were held at each site. No
example, an appeal using fear or guilt as a theme significant differences were reported between the
may serve as strong motivation for a group of sites or various blood drives over time. The bro-
donors but may be ineffective in recruiting nondo- chures were not shown to expand recruitment or to
nors.
facilitate the return of donors who had received a
Much of the earlier literature tended to describe temporary deferral. Although this educational ap-
donors compared with nondonors rather than ex- proach focused on 1 factor of the blood donation
plore the differences within the donor group by decision and resulting behavior, recruitment and
using multivariate analyses. Because such a small retention are multifactorial in nature. The lack of
subgroup (3% to 8%) of the overall population efficacy shown by this intervention may under-
represents regular donors, Ibrahim and Mobley 7~ score the need to design approaches that integrate
pursued forging a strategic linkage between re- multiple variables of equal or potentially greater
cruitment and retention as a means to build and importance to blood donor behavior.
maintain a repeat donor pool. Phone interviews
were conducted with 521 blood donors to deter- CONCLUSIONS
mine differences between "high" and "low" do- Based on the review of the literature for the past
nors. The profile of multiple-giving donors re- 3 decades or more, studies have reported (1) de-
vealed a married man educated at the high school mographic profiles of the populations evaluated,
or trade school level with many friends or relatives (2) what donors and nondonors claim are their
as recipients of blood transfusions and who had major reasons to give or refrain from giving blood,
experienced the blood donation process as highly and 3) general effectiveness of some forms of
satisfactory and convenient. With personal gratifi- social pressure and incentives and potential use for
cation noted as the primary motivator for high long-term retention of donors.
donors, a blood drive campaign focused on promo- Some studies considered pivotal in the literature
tion of self-esteem and humanitarianism would be date from a time period that reflects an earlier
more likely to appeal to this targeted group. donor pool, many of whom are aging or no longer
Frequency of donation might be enhanced serving as donors. 5I More recent surveys, even of
128 GILLESPIE AND HILLYER

large numbers of subjects, often draw the sample chronic overscheduling may be distinct from the
from a limited number and type of blood center, major impediments identified by earlier genera-
representing about 5% to 8% of total donors. 6 tions of donors, v3 Modern sources of positive and
Thus, findings do not necessarily reflect the donor negative motivation axe worth exploring through
pool nationwide. The investigation of the charac- scientifically sound investigations involving repre-
teristics of more contemporary donors has revealed sentative cohorts. Future studies might also pursue
donor profiles largely similar to previous studies, the role of incentives that have been proposed
except for increased proportions of women and historically but never used, such as a tax incentive
minority first-time donors in some cases. Interpre- similar to that given to other charitable dona-
tation of these data should be performed in view of tions. 34
the question of whether demographics mirror the Motivation and behavioral outcomes are not
donor pool to assist in targeted recruitment or if static elements in blood donation, arguing that
targeted recruitment actually leads to the reported well-designed and executed interventions could
demographics. 15 In uncommon cases in which an potentially alter motivations, attitudes, and result-
individual center focused on recruitment of donors ing behaviors. Application of findings from pub-
with atypical demographics (eg, minority donors), lished studies toward design and implementation
an expansion of the number of atypical donors was of interventions to promote donor recruitment and
reported. 6 retention merit a multifactorial approach. Address-
Continued targeted recruitment of the histori- ing a single aspect of the decision-making process,
or ignoring the interplay of knowledge, attitudes,
cally desirable blood donor tends to result in the
motivation, and behavior when assessing potential
same type of blood donor overall. Successful mar-
donors or designing interventions, is less likely to
keting-to 35-year-old white men who are Rh neg-
achieve desired goals.
ative may be a major goal of blood centers, but this
Strategies that focus on retaining return donors
approach is unlikely to diversify the donor pool.
and transforming first-time donors into repeaters
Theoretically, the "best" donor is a "safe" donor
would be beneficial. The reasons underlying the
who is intrinsically motivated to continue donating
decision to give blood the first time tend to differ
on a repeated basis, with gender, age, educational
from the rationale to give repeat donations and
level, or other personal characteristics considered
likely alter over time. Changes in motivation may
as lesser issues.
reflect the life cycle of the donor, moving from the
Few recent studies of donor motivation have first-time donor experience to early repeat (1 to 3
been published. Piliavin's 15 review of the literature times) donor to repeat donor (4 or more times) to
through the 1980s cited issues related to time re- multigallon donor. It In addition to positive forces
quired for the donation process, length of history influencing the decision to donate blood, barriers to
taking, inconvenient hours or location, other donation are also constantly present and may in-
sources of delay, and fear of temporary or perma- terfere with the translation of attitudes, motivation,
nent deferral as major deterrents to initial and and intention into actual behavior. Motivational
repeat donation. Two decades later, these issues factors might be modified in their importance as an
appear to persist. In fact, issues of time and donor individual moves through the donor life cycle,
convenience may be considered even more signif- chooses not to give beyond the initial donation, or
icant obstacles to blood donation now than in pre- stops (lapsed donor). Use of surrogate end points,
vious decades. 3~ The vast majority of nondonors, such as stated intent rather than actual donation
rather than being directly opposed to blood dona- behavior, should be used and interpreted with cau-
tion, actually indicate they would give if "correct" tion. Investigations of what respondents, particu-
conditions were present. 2 Apparently, the "correct" larly nondonors, do not say or are not asked could
conditions are difficult to achieve as evidenced by greatly contribute to the understanding of motiva-
the extremely high rates of nondonors and individ- tional factors impacting the blood donation deci-
uals who drop out after their first donation. 24 The sion.
practical challenges encountered by potential do- Decision making and behavior related to blood
nors who often deal with long commutes, 2-job donation are complex concepts and likely need to
households, care of children and aging parents, and be evaluated on many levels simultaneously. The
BLOOD DONATION DECISION 129

c o m p l i c a t e d nature o f d e c i s i o n m a k i n g r e q u i r e s p r o d u c e g e n e r a l i z a b l e findings. A s n e w deferrals

c l o s e attention to the t h e o r e t i c basis, m e t h o d o l o g i c and the a g i n g p o p u l a t i o n p o t e n t i a l l y i m p a c t the
a p p r o a c h e s , and analytic t e c h n i q u e s u s e d in its current d o n o r base, c o s t - e f f e c t i v e a p p r o a c h e s lead-
study. I n v e s t i g a t i o n s are n e e d e d that u s e o p t i m a l ing to l o n g - t e r m s u c c e s s in d o n o r r e c r u i t m e n t and
m e t h o d o l o g i e s to a s s e s s r e s e a r c h q u e s t i o n s a n d r e t e n t i o n are essential in a s s u r i n g a safe, sufficient,
w e l l - d e s i g n e d strategies to test h y p o t h e s e s and national b l o o d s u p p l y in the future.

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