Blood Donors’ Perception of Incentive Campaigns

Keywords: blood, tissue donation, motivation, propaganda, public health

Abstract

Voluntary blood donation is the only way to supply the hemotherapic system in Brazil and it depends on the population. Inductive campaigns are tools to attract donors, but they seem not to be influencing the donation behavior. This study aimed to investigate the donors’ perception of incentive campaigns for donation. Six donors participated; a number defined by saturation of the content. Data were collected through a sociodemographic questionnaire and semi-structured interview about the motivations to donate, donors’ perception of campaigns to which they were exposed, and their donation experiences. The thematic analysis was used to examine the data. Participants perceive a lack of emotional appeal and insufficient use of social media in campaigns to encourage donation. Results suggest campaigns should use different strategies to reach other audiences, increase the presence in social media, and relate positive feelings to the act of donating.

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Published
2019-09-30
How to Cite
Stephanou, A., & Moreira, M. (2019). Blood Donors’ Perception of Incentive Campaigns. Paidéia (Ribeirão Preto), 29, e2927. https://doi.org/10.1590/1982-4327e2927
Section
Psychology of Health

Blood donation is a fundamental step in the blood transfusion process, an irreplaceable technique in the treatment of several clinical conditions and a valuable subsidy for common surgical procedures in more complex health systems (Aguirre et al., 2013; Charles-Sire, Guéguen, Meineri, Martin, & Bullock, 2014). In Brazil, blood donation was remunerated until the early 1980s, which encouraged people in situations of vulnerability to resort to donation as a form of livelihood (Guerra, 2005). After this practice ended, the strategy of donor uptake focused on replacement donations, those motivated by the punctual need of closer people (Junqueira, Rosenblit, & Hamerschlak, 2005). Seen as a temporary strategy, the biosafety of replacement donations may be lower, considering the emotional incentive to omit information in clinical screening and the sporadic character of this type of donation (Guerra, 2005). Higher rates of communicable diseases in replacement donors were found in studies in Brazil and Egypt (Messih, Ismail, Saad, & Azer, 2014; I.R. Silva & Cardim, 2017) while studies in Turkey and Argentina have not reported differences between voluntary and replacement donations (Iajya, Lacetera, Macis, & Slonim 2013; Yildiz et al., 2015). Prudence should be exercised in the use of replacement donation as a strategy to encourage long-term donation, considering that first-time donors also represent a greater risk of transmitting infections (Kane, Bloch, Bruhn, Kaidarova, & Murphy, 2015; Sun, Lu, & Jin, 2016).

Replacement donations vary in different regions of Brazil, with studies estimating their prevalence in 44% (Araújo, Feliciano, & Mendes, 2011; I.R. Silva & Cardim, 2017), 66% (Liberato et al., 2013), depending on the context investigated, reaching 15% in Florianópolis, the city with the lowest percentage among the Brazilian capitals (R.M.G. Silva, Kupek, & Peres, 2013). The National Agency for Sanitary Surveillance (Ministry of Health, 2018) indicated the percentage of 49% of replacement donations nationwide, which rises to 67% in private services, compared with 46% in public health services.

In this scenario, incentive campaigns for blood donation are a tool used by public and private agencies to capture more voluntary donors and make them recurrent. However, few studies have been found that directly study the impact of campaigns on donation behavior. Pereira et al. (2016) report a critical posture of donors and non-donors regarding the relevance of campaigns and their ability to influence individuals to donate. Liberato et al. (2013), when tracing the donors’ profile in Natal-RN, found 4.8% of blood donations were motivated by campaigns, without specifying their nature. In a study with donors from a blood center in Pelotas-RS, Zago, Silveira and Dumith (2010) found an insignificant relationship between exposure to incentive campaigns and frequent donation behavior; eighty percent of the sample recalled having been exposed to such campaigns at least once. These findings indicate that incentive campaigns are not accurately achieving motivational aspects related to blood donating behavior, possibly failing in the goal of attracting new donors.

In this context, impact of incentive campaigns for donation can be improved by applying decision-making models to voluntary situations. The theory of planned behavior (Bednall, Bove, Cheetham, & Murray, 2013; Wevers, Wigboldus, Van Baaren, & Veldhuizen, 2014) seeks to predict voluntary behaviors through concepts, such as personal attitudes, social norms and perception of control over behavior. Personal attitudes are the individual’s general assessments of a given behavior, which may be subdivided into affective, such as “donating blood will make me feel good” or cognitive: “donating blood is difficult.” The influence of social norms is predicted by investigating how much the individual believes a behavior is socially accepted or expected. The perceived behavioral control refers to how much the person is able to perform it autonomously (Masser, White, Hyde, Terry, & Robinson, 2009). In addition to these three main factors, authors link other constructs to this theory of planned behavior applied to blood donation, including aspects of donor identity (Marta, Manzi, Pozzi, & Vignoles, 2014) and self-efficacy (Clowes & Masser, 2012), which seeks to measure how much the individual feels capable of performing a behavior.

Using the Norm Activation Model, researchers analyzed the impact of factors that activate personal norms related to prosocial behaviors. These factors are the awareness of consequences, the ascription of responsibility, the efficacy of the result, or how the individual behavior of donating helps solving the problem of lack of blood (de Groot & Steg, 2009; Steg & de Groot, 2010). Understanding the way these factors interact with each other and how they can be influenced by communication interventions may serve as a valuable subsidy for the development of more effective campaigns.

Some studies investigate the motivation behind the act of donating blood through concepts such as altruism and benevolence, the latter being understood as the motivation behind acts that benefit both oneself and others (Ferguson, Farrell, & Lawrence, 2008; Gouveia, Santos, Athayde, Souza, & Gusmão, 2014). These concepts relate to both the theory of planned behavior and the norm activation model, as they help to clarify the intrinsic motivations for voluntary donation. More benevolent donors are more likely to be influenced by campaigns that focus on affective attitudes related to blood donation, while altruistic donors would be more attentive to campaigns that highlight the need for donation.

This study aimed to analyze blood donors’ perception of incentive campaigns for donation to subsidize the planning of more urgent incentive campaigns.

Method

Participants

This was a descriptive qualitative study, whose participants were selected for convenience. The recruitment was made by disseminating this investigation in a social network. The inclusion criteria were to be over 18 years old and to have donated blood at least once in the last two years, to favor recent experiences.

Six blood donors participated in this investigation; four women, with a mean age of 20 years and complete or incomplete college degree, and five with per capita family income above three minimum wages. The average of lifelong donations was 4.5. The final number of participants was defined from the saturation of subjects during the analysis.

Instruments

Participants answered a questionnaire of sociodemographic data, to enable group profiling, and a semi-structured interview addressing the thematic of this study. The script was developed by the researchers based on a theoretical review addressing the donation experience (Giacomini & Lunardi Filho, 2010), the context of the first donation and the beliefs related to the importance of blood donation (Ferguson et al., 2008; Gouveia et al., 2014; Steg & of Groot, 2010).

Procedure

Data collection. Interviews were recorded in digital audio and, subsequently, transcribed by the interviewer who, along with another researcher, was also responsible for the thematic content analysis. To maintain confidentiality, each participant received a fictitious name during the transcription.

Data analysis. Data analysis was performed by thematic content analysis, as described by Braun and Clarke (2006), based on the creation of categories guided by the relationship between the content of the interviews and the relevant literature. As it is a descriptive study, its thematic categories were defined a posteriori, thus, the analysis was less influenced by expectations derived from the use of predefined categories.

The analysis was divided into four phases. First, the pre-reading, comprising the moments of interview and transcription, in which the researchers already start familiarizing with the material. After the transcription, the researchers read all the material intermittently, without concern with the coding of meanings. In the next phase, the researchers codified the text in units of analysis, defined as meaningful sentences for this study. These units of analysis subsidized the next phase, which was the categorization of units into comprehensive themes, on which the inferences about the material collected were based. Throughout the process, the analysis units and themes were constantly revised by the researchers to ensure a greater relationship between them.

The final steps of the thematic analysis, related to the categorization of units of meaning, considered the objectives of this study in their relationship with the main postulates of investigations on persuasion, in social communication, applied to the public health promotion and social support to enrich the analysis and promote a broad understanding of the donor uptake and retention process using incentive campaigns.

Ethical Considerations

All participants, before their inclusion in the study, had access to the informed consent form, declaring their willingness to participate in the study. This study was approved by the Ethics Committee - UFCSPA (CAAE 44399415.2.0000.5345).

Results

According to the analysis, three major categories were defined: Incentive campaigns for blood donation; Motivation for donation; and Reflections of blood donation experience. The criterion for the formation of categories was to aggregate statements about a specific aspect of the relationships between the donor, the campaigns, and the act of donating. To provide an analysis from different perspectives, we sought the presence of all categories in the speech of the largest number of participants possible. Likewise, each category appears evenly in the interviews. The category referring to incentive campaigns predominated slightly. We were careful to avoid overlapping of meanings between categories. The analysis system was developed by the researcher responsible for data collection and transcription, and, subsequently, revised and altered by another researcher, by analysis discussion. Each of these categories and the thematic axes of which they are composed will be explored below.

The category Incentive campaigns for blood donation is divided into three thematic axes: criticism of the format and content of the campaigns; considerations on the role of social media in donation process; and analysis of the focus and targeting of the campaigns.

The criticism of the format and content of the campaigns was formed by descriptions of campaigns the participants had contact with. The generic content of the campaigns, predominantly informative and little connected to emotional and personal matters that cause people to donate was highlighted. Clara describes the tone of campaigns as “... a white background, a heart, ‘donate blood’, then a phone number, I don’t know, a 0800 to ask for information” and suggests the use of narratives with emotional content for more engaging campaigns, using as example a retail network known for their exciting campaigns. They also suggested approximating the target audience mentioning that it may need blood donation in the future, as Olívio mentioned, “... This feeling of ‘today you are helping, but tomorrow you may need help’, you know, that feeling has to be well elaborated.”

The participants also showed dissatisfaction with the restricted reach of campaigns which they had contact with. They suggested the use of social media and other alternative strategies to traditional advertising to increase the impact of campaigns. When talking about the campaigns he had contact with, Alan points out: “In the health campaigns I see, they still have to improve this interaction considerably in social media.” Pietra complements the idea: “If it is well publicized on Facebook, it appears to me. (...) Young people spend more time on social networks, no one watchs TV anymore nowadays.”

Regarding the target audience of the campaigns, the participants highlighted the low-income and education level populations, the pre-university and university students as important targets. About the population of disadvantaged classes, Olívio speaks “sure they have a feeling of solidarity that can be, I would not say explored, but... can be beneficial to everyone. If it is well worked, these people can help, very much.” The reception campaigns for freshmen, in which senior students organize joint efforts for blood donation, were also remembered for their informative value “you are shown how it works, everything, at least it was so with me”, according to Alan.

The category Motivation for donation deals with the participants’ descriptions about what makes them donate and their opinions regarding what mobilizes other donors and about which factors do not favor the donation behavior. This category concentrates the pro-social motivation, motivation for personal relationships, lack of information as a barrier and the bureaucracy as an obstacle.

The pro-social motivation is understood here as the one that arises from the will, or the sense of obligation, to act in favor of society. In this study, statements of pro-social motivation were considered those focused on behavior as a way to help other people or society without a known beneficiary, such as a relative or friend in need. Pietra describes her motivation: “My motivation is being able to help at least the minimum I can, right, to do my part, as a citizen.” Eliza associates her motivation with the lack of blood in the system: “We know that there is a large deficit in the amount of blood that is donated, especially on some dates...”.

Motivation for social relations was understood through the reports of motivation for replacement donation, when donation is directed to a friend or acquaintance in need, and the situations in which the individual benefits or is directly influenced by someone to donate. It is different from the pro-social motivation, because the benefit in the relationship between people involved plays a fundamental role in this case. The donation in the campaigns of reception to freshmen in the university, the so-called “solidarity hazing”, enables this scenario. Alan describes: “The one in college you are kind of influenced by the guys. The seniors say, ‘Let’s donate’ (...) ‘Let’s help’, then the freshmen do it for obligation.” Eliza, who believed to be unable to donate by clinical condition, says that “my friend decided to go there and donate it, so she invited me to come along... Because I was not that sure I could.”

Lack of information as a barrier to donation was defined by the reports that characterize the impact of scarce knowledge of donation requirements by the population on attracting new donors. Pietra exposes how myths prevent people from becoming donors “‘Oh, did you get a tattoo? You will never be able to donate blood’,‘are you gay? You will never be able to donate blood.’” Olívio points out that the lack of information can be significant: “... That feeling of fear before you go, of putting a needle in your own body, it’s sort of related to trust, it’s hard. (...) the lack of trust in the institutions, right, it happens, it has a certain importance.”

The impact of bureaucracy as an obstacle to donation emerged from the participants’ statements about how the norms regarding donation, as well as the practical and convenience aspects can influence the motivation to donate. Clara reports the following: “I found it overcrowded (...) and I think many people give up donating [by waiting].” In relation to these aspects, Alan explains that “although you only get there and donate, you have the whole question of feeding hours (...) of the rules for donation.”

Corroborating the idea that it takes a certain time available for donation, the participants also complained about the opening hours of blood collection sites and the difficult access to these sites. Pietra also reports the difficulty for those who work, even with the provision of medical certificate, “... At that time, people are working. (...) the scenario of always delivering medical certificate can become a bad habit sometimes.”

The third category, Reflections of blood donation experience, deals with the participants’ evaluation regarding their experiences during the donation process and the possible impacts of this evaluation on their return. This category encompasses both satisfactory and negative experiences related to donation.

The participants not only reported positive donation experiences, but also described their impact on donor behavior. For Alan, “if the person is well trained (...) and does it right, people tend to return”, explaining the potential of the first donations as a scenario favoring donors’ return and promoting regular donation. Eliza reports how positive experience helps in clarifying myths about donation: “I thought it would hurt much more, and it was very smooth like that, it did not hurt. It’s not that dreadful thing.” The participants highlight, besides the professionals’ welcoming behavior and the absence of pain in the procedure, the feeling of being able to donate as something positive, especially for those who were not sure. Social acknowledgement has a similar role. “When I went there to donate again and they remembered me and said ‘Ah, we ended up donating your blood’, I was totally satisfied,” Clara explains.

The participants also described cases of service with an inadequate posture on the part of professionals involved, as well as problems in the collection that caused pain or discomfort. The impact of these situations on the future behavior of donors was evaluated, with divergent opinions regarding the kind of problem, emotional or physical discomfort would have a greater impact on the evaluation of experience and subsequent donors’ return. On the impact of problems in the collection, Alan says that “I have had the problem in which the person pierced me wrong twice, this may be the reason why the person who goes there for the first time and doesn’t come back”, and reinforces that inexperienced donors can be more impacted by this situation:

As I know the importance (of donating), I know how it differs from person to person who will collect (...) But if the person will donate for the first time, and the person collecting misses his/her vein twice, the person does not come back.

Clara also reports a problem in her first blood donation, and the impact on her expectations of donating: “I went to donate and they made a mistake, I don’t know, I don’t remember what happened, only a little blood was coming out of me, so I started to think I had small veins, right.”

When comparing physical discomfort with difficulties in the care, Olívio believes the expectation of pain is normal in procedures such as donation, which would make the physical discomfort less impactful. Regarding problems related to health teams’ inadequate posture, he points out that “it would be even worse, because you see that when you are not well received, you feel uncomfortable”. Pietra agrees with the negative impact that difficulties in the care can exert, and mentions how much an approach that seeks to welcome the donor helps this donor cope better with negative aspects of the donation: “I have a friend who got very nervous when he went to donate, and the nurse talked to him and he relaxed, then she found his vein, which she was not finding.” Demonstrating how the experience of donating can influence the overcoming of such uncomfortable situations, some participants, such as Amelia, reported a strategy to deal with unsatisfactory service: “[if I] received a bad service, I would no longer return to this place, I would donate in another one.”

Discussion

In this study, the concept of incentive campaigns for donations exceeded the idea of mass media campaigns, since the participants cited greater contact with incentive campaigns of friends or small groups, as in the “solidarity hazing” in university. Even the participants who reported pro-social motivation pointed out the importance of these actions to promote the search for information about the donation, and how they can be a gateway to a potential donor. Guiddi, Alfieri, Marta, and Saturni (2015) emphasize the importance of this sense of social bonds in donor loyalty, suggesting that the collection sites can also become sites for social interaction between donors and potential donors.

This action, in which the social benefit of participation is evident, can be considered a divergence of the concept of blood donation as a purely altruistic act. This concept is used in several studies (Giacomini & Lunardi Filho, 2010; Gouveia et al., 2014; Hillgrove, Doherty, & Moore, 2012). In counterpoint, Ferguson et al. (2008) characterize donation as a benevolent act, considering that donors are somehow rewarded, such as in the consolidation of new social relations. Based on this premise, one recommends that actions to encourage donation consider the possibility of personal gain resulting from solidarity behaviors, especially from those hardest to perform, such as blood donation.

Gouveia et al. (2014) propose that behaviors to help others can be motivated by the fear of needing this help in the future, which supports the participants’ suggestions for developing campaigns that imply the possibility of needing donation someday. However, one recommends prudence with incentive campaigns that promote donation by provoking negative emotions, which can cause negative attitudes towards donation and less intentions of donating (Clowes & Masser, 2012). Reid and Wood (2008) recommend relating positive emotions, such as social acknowledgment and personal satisfaction, to the act of donating. Pereira et al. (2016) point the lack of social acknowledgment and the importance that it is valued in the incentive campaigns for donation.

Also on the content of the campaigns, the participants positively mentioned campaigns informing that a donation can save more than one person, increasing the importance of donating. Sun et al. (2016) analyzed the results of an intervention based on warning donors of the lack of blood, pointing out that a message informing the greater need favors the act of donating blood among donors. It makes sense that donor-targeted campaigns emphasize the importance of each donation. Steg and De Groot (2010) also highlight the importance of the efficacy of individual behavior for people who are already sensitized to donate blood. In non-donor campaigns, emphasizing the need for the system in general would be important, to thus reinforce the impact of the individual behavior.

Regarding the scope of the campaigns, the importance of using social media was highlighted, and it was suggested that campaigns with greater emotional appeal would have greater potential for sharing, reaching a wider audience than in traditional media. Few references to campaigns to encourage blood donation in social media are made in the scientific literature. Godin, Vézina-Im, Bélanger-Gravel, and Amireault (2012) also cite the lack of records on the use of new technologies in encouraging blood donation, even though the internet is increasingly an interesting mean to reach several people (Reid & Wood, 2008). Pointing out that the dissemination of social media is a recent phenomenon and that the Brazilian population, especially young and university students, as the participants in this study, uses these media more often than the rest of the world is important (GlobalWebIndex, 2015). This explains why a niche pointed as extremely important by the participants does not present a history of investment in actions of donation promotion. Still, this may indicate a lack of scientific records of development and implementation of promotion strategies for donation in Brazil, which would be a great help in disseminating advances in the area.

Some participants also highlighted the unexplored potential of low income and education donors. Besides the record that the profile of donors in Brazilian blood centers tends to have a higher income and schooling and to be generally formed by young men (Belato, Weiller, Oliveira, Brum, & Schimith, 2011; Liberato et al., 2013; Zago et al., 2010), no study in Brazil investigated the reasons for the low participation of populations with lower income and schooling in blood banks. Pereira et al. (2016) highlight the general impact of the lack of information and trust in health institutions in Brazil. Lack of information as a barrier to donation is reported in studies from countries of the Americas and the Caribbean (Belato et al., 2011; García Gutiérrez, Sáenz de Tejada, & Cruz, 2003; Gillespie & Hillyer, 2002). The assumptions agree with the participants’ answers in this study that the less favored populations have lower confidence in institutions (R.M.G. Silva et al., 2013) and are more affected by myths about the risks of blood collection process. Likewise, they elicit the possibility that practical difficulties to donate, referring to displacement and inclusion of donation in routine, have a greater impact on this population, which would set a low perceived behavioral control (PBC) in the theory of planned behavior (France et al., 2014). In this scenario, the investigation of characteristics of these populations regarding their perceptions about blood donation process would be relevant to institutions responsible for blood collection.

The participants mentioned the rigidity of donation norms as a significant obstacle, both for regular and first-time donors. Other concerns regarding donation norms are related to the difficulty in organizing to be well fed at the time of collection, reserving the necessary time in the routine, as well as not doing physically demanding activities after the donation. Considering that these donation norms aim at promoting the proper care for both the blood collected and the donor, imagining changes in these parameters in the near future would not be indicated. Thus, campaigns that seek to reduce the impact of these norms as barriers to donation could focus on the development of self-efficacy as a main strategy. Self-efficacy has been used both as addendum to the theory of planned behavior and as a substitute for the PBC (Clowes & Masser, 2012; Masser et al., 2009), being one of the main predictors of intention to donate.

Regarding the reinforcement of regular donation, the participants were emphatic in putting the experience of donation as a fundamental aspect in facilitating the return of a first-time donor. The importance of a satisfactory experience to encourage the donors’ return and loyalty is well documented in literature (Araújo et al., 2011; Custer et al., 2012; Dongen, Ruiter, Abra’ham, & Veldhuizen 2014; Giacomini & Lunardi Filho, 2010), corroborating the participants’ reports. Also, the concept of self-efficacy can be related to favoring donors’ return, relating it to the report of the two most frequent donors from this study, who reported that faced with unsuccessful service, they would search for other places of donation to not stop donating blood. This report describes that high self-efficacy favors the overcoming of more and more obstacles to perform the behavior in question (Masser et al., 2009; Wevers et al., 2014). Although the participants did not report a perception of a previous training of the professionals involved in the collection to receive the donors, it is important they are able to deal with emotional issues that arise during the clinical screening interview as well as the use of techniques that help to reduce the occurrence of adverse reactions to donation, to neutralize the impact of negative experiences, which hinder the return (Bednall et al., 2013; Custer et al., 2012; Dongen et al., 2014). One can also assume that positive experiences facilitate the development of a donor identity, a factor also connected to the maintenance of regular donors (Dongen et al., 2014; Masser et al., 2009; Wevers et al., 2014). Therefore, strategies that reinforce self-perception as donors in individuals can collaborate for the return of first-time donors. These strategies can be developed both in mass media and in the constant qualification of service and blood collection teams.

Finally, our study built a critical posture of donors regarding incentive campaigns, with participants pointing potential for improvement in points such as the content of campaigns, which is very informative and makes little emotional appeal and their limited range, with low exploitation of social media.

Regarding campaigns to encourage donor’s return, results indicate the importance of a positive experience. Considering that more experienced donors have greater ease of dealing with negative donation experiences, giving special attention to first-time donors and reinforcing in them the donor identity and the feeling of self-efficacy is necessary. With these possibilities, studies that experimentally investigate motivational aspects are relevant to blood banks and other institutions responsible for the development of incentive campaigns.

It is important that the development of incentive campaigns takes into account the multiplicity of motivational factor reported in this study, which illustrates the need for campaigns with different contents to reach different audiences (Guiddi et al., 2015). Considering the lack of experimental studies on these theories in the Brazilian context, the conduction of studies that seek to verify the applicability of these concepts to this population is recommended. Segments pointed out in this investigation, such as low-income and education populations should receive attention, as well as non-donors, not directly herein addressed. This would allow a better understanding of the role of obstacles in the decision to donate, which were related to the lack of adequate information, favoring the proliferation of myths about the minimum requirements for donation. Exploring the potential of campaigns in social networks, and on the internet as a whole, which was neglected so far in scientific literature but is rather present in the daily life of donors participating in this study, is suggested. This platform is expected to enable more personalized and interactive campaigns, which can show more solid results, especially with populations more attentive to social media.

The homogeneity of the group is a limitation of this study, not allowing generalization of results. On the other hand, this study did not intend to establish rigid parameters, but to raise alternatives for further investigations that subside the development of campaigns in the area. Results point the potential of campaigns with greater emphasis on positive feelings associated with the act of donating blood. Campaign dissemination should prioritize social networks, especially when it is directed to young donors. Experimental studies that measure the intention to donate before and after exposure to campaigns are a way to develop more effective materials. Again, a distinction between non-donors, first-time donors and loyal donors must be made, considering that these groups deal in different ways with the factors that permeate the decision to donate blood.

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Support: Article derived from the first author’s final course paper under the second author’s supervision, defended in 2015 for obtaining a degree in Psychology from Universidade Federal de Ciências da Saúde de Porto Alegre.