Introduction:
Blood transfusion has been recognized as one of the eight key lifesaving interventions in health care facilities [1]. World Health Organization (WHO) estimates that blood donation by 1% of the population is generally the minimum needed to meet a nation’s primary requirements for blood [2]. However, most of the developing and transitional countries have a blood donation rate of less than 1% [3]. In India, more than 38,000 blood donations are needed every day and a total of 30 million blood components are transfused each year [4]. The disparity between demand and supply mandates establishing a robust transfusion service, focusing on effective donor education, motivation, and recruitment strategy [5]. Globally, attempts to meet the Millennium Development Goals 4, 5 and 6 will not be achieved without persistent efforts by individual countries and the global community to develop safe and sustainable blood supplies [6].
Worldwide, an estimated 38% of reported voluntary blood donations (VBDs) are contributed by people under the age of 25 years. Blood donation by young students is preferred because of the possibility of recruiting them at a young age and the subsequent potential of making them regular donors and motivators, which in turn will provide a perennial supply of safe blood [7].
Higher educational institutes (HEIs) provide a pool of potential blood donors. Paucity of studies to assess knowledge, attitude, practice, and behavior of students in India beyond the focal institute of the researcher, limited number of participants, and dearth of concrete recommendations justify undertaking this study. This may inspire non-donors to start donating blood and motivate people to donate blood on a regular basis [8].
Materials and Methods
This survey was conducted among students of various HEIs across India using a pre-designed, pre-tested, semi-structured questionnaire. The questionnaire was electronically administered to all participants.
Permission from the designated authorities of all HEIs approached was obtained before actual data collection. Participation in the study was completely voluntary and the students were assured that their responses would be kept confidential and utilized only for research purposes. Approval for conducting the study was obtained from an Independent Ethics Committee (IEC). The study was conducted during January 2018–May 2018.
The questionnaire was administered to all students of the selected HEIs. From these HEIs, 7992 students responded to our call, of which 711 students did not consent to participate. Thus we obtained responses from 7281 students.
The questionnaire contained five sections and included dependent and independent variables. There were a total of 42 questions in five sections: sociodemographic characteristics, knowledge, attitude, practices, and behavior (past, observed, and intended) of the participants concerning blood donation. A few questions were on assessing the efficacy of intervention strategies in recruiting voluntary donors.
A scoring mechanism was used to understand overall knowledge level. The score of one was given for each correct response and score of zero for a wrong response. There was no negative marking. Based on the total score, the knowledge level of the participants regarding blood donation was categorized into below average (<10 points) and average and above average (>10 points).
All statistical analysis was performed using SPSS for windows (version 1.0; SPSS, Chicago, ILL). Continuous variables are presented in the summary statistics of the number of participants (n), mean, standard deviation, and median by appropriate groups. All statistical tests were two-sided and evaluated at 5% level of significance.
Descriptive analysis was done for data summarization. For continuous variables, means with their respective measures of dispersion were used, while proportions were used for categorical data. Frequency and percentage were used to assess the sociodemographic data as well as the level of knowledge, attitude, and practice of these students.
Inferential statistics was deployed to study the associations between the demographic factors which were analyzed by using the chi-square test. One-way analysis of variance (ANOVA) was carried out to find out the association between knowledge, attitude, and practice scores and the selected demographic variables.
After assessing the normality of distribution of the data, logistic regression analysis was applied. A multivariate logistic regression was used to examine the effect of two or more independent variables on a single dependent variable to test the statistical significance at 95% confidence level. Adjusted odds ratios were computed for each explanatory variable to determine the strength of association with outcome variable and to control the effect of confounding factors.
Results
Out of 7992 students, 7281 agreed to participate, giving a response rate of 91%. Of the 711 students (9%), who refused to participate, 448 (63%) reported that they were busy and did not have time to participate and 63 (37%) did not participate as they were not interested in the study.
The mean age of the participants was 28.9 (±9.3) years and varied from 18 years to 34 years. Zone-wise distribution of participants showed maximum responses (39.4%) from the west zone states and minimum responses (9.8%) from the central zone states. There were 120 (1.7%) international students. Number of undergraduate students was 4695 (64.5%) as compared to the postgraduate students who were 586 (35.5%; see Table 1).
| Table 1: Socio-demographic characteristics of participants |
|
Frequency |
Percent |
N |
7281 |
|
Gender |
Male |
3485 |
47.9 |
Female |
3796 |
52.1 |
Average age of participants in years |
28.9 |
+9.3 |
Nationality of the participants |
Indian |
7161 |
98.3 |
International |
120 |
1.7 |
Zone wise distribution of participants |
North |
1790 |
25.0 |
South |
1102 |
15.4 |
East |
744 |
10.4 |
West |
2822 |
39.4 |
Central |
703 |
9.8 |
Programme enrolled for |
Undergraduate |
4695 |
64.5 |
Postgraduate |
2586 |
35.5 |
Faculty wise breakup |
Management |
2370 |
32.6 |
Health and Biological Sciences |
1436 |
19.7 |
Law |
950 |
13.0 |
Media, Communication and Design |
837 |
11.5 |
Engineering |
656 |
9.0 |
Information Technology |
556 |
7.6 |
Other |
476 |
6.5 |
From all participants, 5606 (77%) knew that the right age for being eligible to donate blood was 18 years. 3398 (46.7%) participants were aware of the cutoff value of 12.5 g/dl of hemoglobin for being eligible for blood donation. That they could donate blood once every three months was known to 3712 (51%) of the participants while 6065 (83%) of the participants were aware that blood is screened for some diseases before transfusion. Out of 7281 students, 4667 (64.1%) had above average knowledge (average score 12); 614 (35.9%) had below average knowledge concerning blood donation.
Not a single participant was able to respond to the knowledge part of the questionnaire with 100% accuracy. As opined by 5610 (77%) participants, voluntary blood donation is the best source of donor blood. Monetary compensation for blood donation was not felt to be a good practice by 4124 (56.6%) of the participants. Getting more than five on the scale of 1 to 10, 6585 (90.4%) participants were enough motivated to donate blood. Out of all, 592 (35.6%) participants had donated blood at least once whereas 4689 (64.4%) had never donated blood. Of these non-donors, 1841 (39.3%) had not done so due to lack of opportunity whereas 1630 (34.7%) did not have information regarding the same. There was a fear of the procedure in 316 (31.8%) participants whereas 991 (41.1%) participants were afraid that they faced the risk of transmission of diseases by donating blood. To be a regular donor, 3919 participants (53.8%) were willing. Most common reason for donating blood among both undergraduate and postgraduate students was peer pressure, which led to 50.2% of the blood donation they made. Other parameters evaluating knowledge, attitude, behavior, and practice parameters regarding VBD are depicted in Table 2.
| Table 2: Responses regarding select knowledge, attitude, behavior and practice parameters regarding VBD |
| Selected knowledge parameters |
Frequency |
Percent |
Minimum age eligible for blood donation |
16 years |
912 |
12.5 |
18 years |
5606 |
77.0 |
21 Years |
206 |
2.8 |
Don’t know |
396 |
5.4 |
No minimum age |
161 |
2.2 |
Minimum weight required to be eligible for blood donation |
40 Kg |
230 |
3.2 |
45 Kg |
1240 |
17.0 |
50 Kg |
2357 |
32.4 |
Depends on height |
2596 |
35.7 |
Don’t know |
858 |
11.8 |
Minimum level of Haemoglobin required for blood donation |
Up to 10 g/dl |
322 |
4.4 |
11 g/dl to 12.5 g/dl |
1799 |
24.7 |
>= 12.5 g/dl |
3398 |
46.7 |
No minimum limit |
30 |
0.4 |
Don’t know |
1732 |
23.8 |
Individual of which blood group is the Universal Donor? |
O +ve |
5270 |
72.4 |
O –ve |
1552 |
21.3 |
AB +ve |
203 |
2.8 |
AB –ve |
36 |
0.5 |
Don't know |
220 |
3.0 |
Individual of which blood group is the Universal Recipient? |
O +ve |
564 |
7.7 |
O –ve |
458 |
6.3 |
AB +ve |
4898 |
67.3 |
AB –ve |
620 |
8.5 |
Don't know |
741 |
10.2 |
How much blood is collected from a single donor during blood donation? |
150 – 250 ml |
2198 |
30.2 |
250 - 350 ml |
1151 |
15.8 |
350 - 450 ml |
2692 |
37.0 |
Don’t know |
1240 |
17.0 |
Number of patients who can benefit from 1 unit of whole blood |
1 |
1232 |
16.9 |
2 |
1022 |
14.0 |
3 |
1502 |
20.6 |
> 3 |
1426 |
19.6 |
Don’t know |
2099 |
28.8 |
Frequency of blood donation |
Once every 3 months |
3712 |
51.0 |
Once every 6 months |
2557 |
35.1 |
Once a year |
284 |
3.9 |
As frequently as possible |
213 |
2.9 |
Don’t know |
515 |
7.1 |
Awareness regarding possibility of some diseases being transmitted (TTD) through blood transfusion |
Yes |
6065 |
83.3 |
No |
455 |
6.2 |
Don't know |
761 |
10.5 |
Is it mandatory to obtain CONSENT prior to blood donation? |
Yes |
6317 |
86.8 |
No |
442 |
6.1 |
Don't know |
522 |
7.2 |
Overall knowledge score |
Below average |
2614 |
35.9 |
Average and Above |
4667 |
64.1 |
Best Source of Donor Blood |
Voluntary donor |
5610 |
77.0 |
Replacement donor |
283 |
3.9 |
Paid-Professional donor |
623 |
8.6 |
Don’t Know |
765 |
10.5 |
Is it a good practice to donate blood in return of money? |
Yes |
1000 |
13.7 |
No |
4124 |
56.6 |
Cannot comment |
2157 |
29.6 |
Have you ever donated blood? |
Yes |
2592 |
35.6 |
No |
4689 |
64.4 |
If yes, what is the number of times you have donated blood till now? |
Once |
1139 |
43.9 |
More than once |
1453 |
56.1 |
Total |
2592 |
|
Are you willing to be a regular donor? |
Yes |
3919 |
53.8 |
No |
900 |
12.4 |
Cannot say |
2462 |
33.8 |
Knowledge regarding blood donation differed for both genders; more males (37.5%) had better knowledge than females (27.9%). The motivation score was found to be above 5 in 853 (81.9%) male participants as compared to score above 5 in 976 (78.4%) female participants (p=0.0001). This implies that the attitude regarding blood donation is also gender-dependent. Similarly, practice of blood donation was also found to be gender-dependent. Out of a total of 2592 participants who had donated blood, there were 1781 (68.7%) males and 811 (31.3%) were females. There was a good co-relation between knowledge and attitude (Table 3).
| Table 3: Characteristics of participants by knowledge score. |
|
Total |
Below average |
Average and above average |
P-Value |
Gender |
Male |
3485 |
1107 (42.3) |
2378 (51.0) |
0.0001 |
Female |
3796 |
1508 (57.7) |
2288 (49.0) |
|
Which programme have you enrolled for? |
Undergraduate programme |
4695 |
1635 (62.5) |
3060 (65.6) |
0.009 |
Postgraduate programme |
2586 |
980 (37.5) |
1606 (34.4) |
|
To which faculty does your programme belong? |
FoHBS |
1436 |
634 (24.2) |
802 (17.2) |
0.0001 |
Others |
5845 |
1981 (75.8) |
3864 (82.8) |
|
Is it a good practice to donate blood in return of money? |
Yes |
1000 |
328 (12.5) |
672 (14.4) |
0.023 |
No |
4124 |
1531 (58.5) |
2593 (55.6) |
|
Cannot comment |
2157 |
756 (28.9) |
1401 (30.0) |
|
Have you ever donated blood? |
Yes |
2592 |
935 (35.8) |
1657 (35.5) |
0.835 |
No |
4689 |
1680 (64.2) |
3009 (64.5) |
|
What is the number of times you have donated blood till now? |
Once |
1139 |
387 (41.3) |
752 (45.4) |
0.014 |
More than once |
1453 |
558 (58.6) |
901 (54.6) |
|
Are you willing to be a regular donor? |
Yes |
3919 |
1515 (57.9) |
2404 (51.5) |
0.001 |
No |
900 |
275 (10.5) |
625 (13.4) |
|
Cannot say |
2462 |
825 (31.5) |
1637 (35.1) |
|
The participants were motivated towards VBD by different factors and recognition, need of friends and relatives, and an altruistic attitude are the major drivers. Incentive for donating blood does not feature among the prime motivators (Figure 1).
 |
Fig 1: Percentage distribution of factors that motivate participants to donate blood (*Multiple responses so addition may exceed 100%) |
Diverse opinions regarding strategies to promote VBD amongst students of HEIs is represented in Figure 2.
 |
Fig 2: Percentage distribution of reported strategies to promote blood donation among students (*Multiple responses so addition may exceed 100%) |
Regression analysis reveals that males aged 25 years or above pursuing postgraduate education are 1.5 times more knowledgeable (confidence interval 1.338–1.904). However, this higher level of knowledge does not necessarily translate into actual practice of blood donation (Table 4).
| Table 4: Logistics regression for better knowledge and practice regarding voluntary blood donation |
|
|
Knowledge |
|
|
Practice |
|
|
|
|
|
95% CI |
|
|
|
95% CI |
|
|
|
Exp (B) |
Lower |
Upper |
p-value |
Exp (B) |
Lower |
Upper |
p-value |
Gender |
Female |
1 |
|
|
|
1 |
|
|
|
Male |
1.523 |
1.367 |
1.696 |
0.0001 |
0.278 |
0.247 |
0.312 |
0.0001 |
Age (y) |
<=25 |
1 |
|
|
|
1 |
|
|
|
>25 |
1.121 |
.937 |
1.342 |
0.212 |
1.596 |
1.338 |
1.904 |
0.0001 |
Education |
Under-graduation |
1 |
|
|
|
1 |
|
|
|
Post-graduation |
1.184 |
1.044 |
1.343 |
0.009 |
2.448 |
2.154 |
2.782 |
0.0001 |
Knowledge score |
|
|
|
|
|
|
|
|
Less than average |
-- |
-- |
-- |
-- |
1 |
|
|
|
Average and more |
-- |
-- |
-- |
-- |
1.009 |
.895 |
1.138 |
0.879 |
Discussion
While the research published to date studied on sample sizes varying from 100 to 1000 [1,4,9]. Our study, however, has the largest sample size so far. From a total of 7281 students, 3485 (48%) males as compared to 3796 (52%) females responded to the questionnaire for the current study. Similar male to female ratios have been quoted in other studies as well [10, 11]. We enrolled 4695 (64.5%) undergraduate participants as compared to 586 (35.5%) postgraduate participants, which gives the ratio of 1.8:1. This is also the first study to enroll 120 students from other countries in addition to the students from the country under study. This adds to the heterogeneity of the sample population.
Of the participants, 4667 (64.1%) had above average knowledge regarding blood donation. This is higher than several other studies [10,12-15] have reported. This can be explained by the fact that being university students, they live in a learning environment and directly or indirectly gain knowledgeable information.
There was a significant difference in the level of knowledge about blood donation between male and female participants. Knowledge and practice of donation was better in males than females. Most of the findings of this study are similar to those of the other studies that used college students as sample [15-17].
In the present study, 592 (35.6%) had donated blood at least once. This is a similar result to studies conducted in India [13,15,18,19]. Internationally too, similar figures have been quoted [20,21]. Of all respondents, 3919 (53.8%) were willing to donate blood in future. This too is similar to results of other studies [3,4,22,23].
A total of 1841 (39.3%) of students had not donated blood due to lack of opportunity. This is alarming, given the number of blood donation camps organized frequently and at various places. This could probably be because there are HEIs, despite their historic standing, who have not conducted a single blood donation camp to date! (For reasons best known to the authorities; could be fear / apprehension of possible side effects OR simple apathy on part of the authorities of the HEIs).
In the current study, it was observed that, of the total no. of blood donors, 1781 (68.7%) were males and 811 (31.3%) were females. This gender-wise difference among the participants who had donated blood in the past is congruent with other studies [1,12,24-27].
The reasons for this difference could be that males are more involved in outdoor activities, decision making, or simply getting more opportunities. Further, males are easier to be approached or informed. The reasons for fewer female donating blood than males could be deferral conditions like low hemoglobin values, low weight, fear of pain, or occurrence of menstruation [28]. Occurrence of menstruation has also been found to demotivate girls from donating blood [29].
Focusing on improving the health of women in our society will definitely improve the status of VBD amongst female participants in India where only 6% women donated blood in 2011 [30]. Deferrals on grounds such as periods, pregnancy, etc. should be counseled as regards their temporary nature and females should be assured that they can become healthy eligible donors in future [31].
The current study shows that 4689 (64.4%) of the participants had never donated blood. These results are in accordance to other studies [1,12,15,21]. From among the participants, 3919 (53.8%) responded that they were willing to donate their blood and be a regular donor in future. Although first-time donors are important for the recruitment strategy, high dropout rate underscore the need to address the factors, which are related to retaining the donors. VBD was confirmed as the best source of blood by 5610 (77%) participants, a result again similar to other studies [7,18,19,23].
Non-donors with a positive attitude should be motivated and awareness about VBD should be provided to promote blood donation on a voluntary basis, while non-donors with a negative attitude need to be educated about the importance and health benefits of blood donation. Their doubts regarding blood donation should be clarified to motivate them to donate blood on a regular basis.
In the present study, source of information regarding blood donation was electronic media/TV and radio for 3142 (43.2%) participants, print and social media for 846 (39.1%), followed by friends and family/relatives for 4400 (60.4%). Another study in India also reported similar findings [24]. As expected, mass media plays a crucial role in informing people about blood donation.
To address the lack of opportunity and the issue of insufficient information in not donating blood, there is an urgent need of creating enough opportunities for blood donation. Blood banks would be better off organizing blood donation camps at university premises on a regular basis to suite the student’s convenience [32]; in fact, it should be made mandatory by the health department/higher education department that every HEI must have one blood donor society and the society must arrange at least one blood donation camp in the university premises every year. In this way, the chances of increasing the blood donor pool will be augmented.
Of the participants, 1998 (27.4%) thought that offering incentives for blood donation would work; of these, 405 (5.6%) were in favor of incentives like money or token gift. Other studies have observed that 9% of the participants preferred some incentives [27] for donating blood. In a study in the Kingdom of Saudi Arabia, majority of donors (85%) disapproved the idea of giving money to donors but 63% accepted the idea of a token gift [8]. Offering blood credits, medical testing, and items of limited value could be safe and effective strategies for retaining the existing donors [33].
Strategies like organizing transport to the venue of donation and rewarding blood donor cards/certificates may be considered as ethical, safe, and effective ways to attract and retain donors. Promotional campaigns for VBD should focus on the unselfish act of donating blood to save lives and sending out simple clear messages to educate and dissipate myths associated with donation should be propagated.
Of the participants, 3012 (41.4%) mentioned conscience/morality/altruism as one of the motivating factors to donate blood. It is important to note that altruism does come out as the main driving force for blood donation in this study.
Of the participants, 5752 (79%) opined that creating awareness is the best strategy to promote blood donation amongst students of HEIs. This may be effectively achieved by formal education through need-based as well as altruistic “smart” messages [32].
Conclusion
The current study employs the largest sample size of 7992 reported in the literature till date. It provides useful insights into perception and practices of VBD amongst students of HEIs in India. In order to improve the blood donation rate, regulatory bodies can frame a national policy for recruitment and retention of voluntary blood donors and focus on changing the blood donation culture from that of replacement to volunteerism. Re-
emphasizing that commercial blood donation is legally prohibited would promote VBD.
Corporate organizations can be incentivized to promote VBD as a corporate social responsibility. Blood banks and NGOs can develop strategies to retain (recognize) voluntary blood donors and ensure safe blood donation experience. Building partnership with media (especially social media) is crucial. Authorities of HEIs can promote and foster a culture of VBD by ensuring the buy in of students. This includes conducting blood donation camps ‘on campus’ to positively leverage the peer pressure of colleagues and also to suit the ‘convenience’ of students. Ensuring the buy in of students is critical.
Even though this study considered a huge sample size, it may still not be representative of the large pool of students at HEIs in India. Results of further studies may therefore be required to support the findings and in turn help stakeholders in designing different strategies to encourage blood donation on a regular basis.
Acknowledgement
The researchers duly acknowledge the support of the authorities of all HEIs and cooperation of the students who participated in this study.
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