can family or replacement blood donors become regular volunteer donors?

D O N O R R E C R U I T M E N T A N D M O T I V A T I O N

Can family or replacement blood donors become regularvolunteer donors?

Kwame Asenso-Mensah, Gifty Achina, Rita Appiah, Shirley Owusu-Ofori, and Jean-Pierre Allain

BACKGROUND: In sub-Saharan Africa (SSA) con-firmed viral marker prevalence between family donors(FDs) and first-time volunteer nonremunerated donors(VNRDs) is similar. In a blood service collecting 10units/1000 inhabitants, a questionnaire examined FDdonation conditions and willingness of becoming repeatVNRDs.STUDY DESIGN AND METHODS: Four areas wereexplored: circumstances of visit to hospital, externalpressure, experience of donating, and potential repeatdonation. After donation and consent, research assis-tants administered 25 questions and, according to lit-eracy, helped with translation and completion.RESULTS: Of 513 FDs, three-fourths were males(median age, 27 years). Only 1.3% were unemployedand more than 50% were students or teachers. Tieswith hospitalized patient were family (76%), friends(13%), colleagues, or sharing place of worship (10%).Donating blood was the reason for visiting in 16.8% and20.9% had previously donated blood probably as FDs.In one-third of FDs, the family asked for donation ofwhich 10% was pressured by the unjustified reason thatnot donating was endangering the patient’s life. Fortwo-thirds of FDs, donation was given “because indi-viduals were asked.” Donation was a positive experi-ence for 77% of donors, 62% being interested inpredonation testing. Repeating donation was acceptablefor 99% of 79% FDs answering.DISCUSSION: FDs are active in the population, arewilling to donate blood if asked, are submitted to littlepressure, do not receive incentives, and accept repeatdonation. Except for circumstances of donation, FDsare not different from VNRDs and more directly moti-vated. They constitute a legitimate and importantsource to improve the blood supply in SSA.

Blood shortage has been until recently a constantfeature of blood transfusion in sub-SaharanAfrica (SSA). Financial and technical supportprovided by developed countries in Europe and

North America has been intended primarily to address thesafety issue of human immunodeficiency virus (HIV)transmission by transfusion with little concern regardingthe blood shortage.1 The strategy promoted by the WorldHealth Organization (WHO) in that respect is clearlystated: “Mindful that preventing the transmission of HIVand other bloodborne pathogens through unsafe bloodand blood-product transfusions require the collection ofblood only from donors at the lowest risk of carrying suchinfectious agents; . . . voluntary, nonremunerated blooddonation is the cornerstone of a safe and adequatenational blood supply that meets the transfusion require-ments of all patients.”2 To this end, considerable effort wasdedicated to recruiting volunteer nonremunerated donors(VNRDs) under the assumption that the family or replace-ment donors (FRDs) traditionally recruited as blooddonors in SSA were less safe than VNRDs and could not bedifferentiated from paid donors who were known to carryhigh prevalence of viral markers.1 This policy had twonegative consequences: perpetuating the blood shortageand increasing the cost of blood transfusion.3 In addition,recent data collected in four sub-Saharan African

ABBREVIATIONS: FD(s) = family donor(s); FRD(s) = family or

replacement donor(s); KATH = Komfo Anokye Teaching

Hospital; SSA = sub-Saharan Africa; VNRD(s) = volunteer

nonremunerated donor(s).

From the Transfusion Medicine Unit, Komfo Anokye Teaching

Hospital, Kumasi, Ghana; and the Department of Haematology,

University of Cambridge, Cambridge, UK.

Address reprint requests to: Shirley Owusu-Ofori,

Transfusion Medicine Unit, Komfo Anokye Teaching Hospital,

PO Box 1934 Kumasi, Ghana; e-mail: sowusu_ofori@

hotmail.com.

Received for publication February 7, 2013; revision

received March 14, 2013, and accepted March 14, 2013.

doi: 10.1111/trf.12216

TRANSFUSION 2014;54:797-804.

Volume 54, March 2014 TRANSFUSION 797

mailto:[email protected]

mailto:[email protected]

countries indicated clearly that the assumption of lowerblood safety of FRDs than VNRDs was not supported byevidence when applied to first-time VNRDs.4-7 Since 60%to 80% of VNRDs were first-time donors, the vast majorityof SSA donors whether VNRD or FRD were epidemiologi-cally undistinguishable. In contrast, the prevalence ofconfirmed viral markers was considerably lower in VNRDswho gave blood at less than a 1-year interval (repeatVNRD) leading to the conclusion that repeating donationwas the key to improved blood safety.8

Since FRDs appear virologically as acceptable asVNRDs and SSA countries having adopted a VNRD-onlypolicy with external help suffer the same level of bloodshortage as those who do not, it appears legitimate todraw on both types of donors as the immediate solution toimprove the blood supply and reach the target of 10 units/1000.1,9 This target was achieved at the Komfo AnokyeTeaching Hospital (KATH) in Kumasi, Ghana, since 2010and maintained until present with approximately 70% ofblood from VNRDs and 30% from family donors (FDs)instead of FRDs since they were no longer replacing trans-fused blood.10 In 2007, Bates and colleagues11 reviewingthe issue of replacement blood donors in SSA pointed outthat “burdening patients’ families with the responsibilityof finding replacement blood donors will exacerbatepoverty and reduce the safety of the blood supply.” Todate, evidence showing exacerbation of poverty has notbeen published. In 2012, a WHO expert group published aconsensus statement for blood and blood product self-sufficiency indicating: “In many countries, systems basedon family/replacement donation are currently in use forproviding blood for patients. These systems, however,often lead to coercion and place undue burden onpatients’ families and friends to give blood, also leading tosystems of hidden payment. Such systems are unreliable,putting the onus for the provision of blood on the patients’families rather than on the health system.”12 However,none of these assumptions have been supported by evi-dence and the various types of “burden” imposed on fami-lies have not been substantiated.

The situation in Kumasi at the time of this study wasdifferent on several accounts. First, the previously opera-tional system of discounting approximately half of theblood cost to the family when a replacement unit wasobtained had been discontinued in 2010 and a single feeof approximately $18/unit of blood transfused is chargedto patients. Secondly, the coexistence of volunteer blood(65%-70% of total supply) and FD blood at an aggregatedlevel of 10 units/100 inhabitants has minimized theblood shortage that would justify mandatory bloodreplacement.10 This situation eradicated the need forpaid donors and created a new environment in whichfamily members are asked to donate in order to help inmaintaining a healthy blood supply for patients in thehospital.

In an attempt to collect evidence to clarify this impor-tant debate, a questionnaire was devised to determine theconditions in which FDs at KATH were recruited, how theyfelt about the experience of giving blood, and whether ornot they would be willing to repeat blood donationintended for an unknown recipient instead of being trig-gered by the need of one of their relatives or friends. Aftera pilot phase (September to December 2011) examiningthe feasibility of the study and the suitability of the ques-tionnaire, the final version was administered to more than500 FDs; the data collected were analyzed and arereported here.

MATERIALS AND METHODS

The study was conducted at the blood donor clinic atKATH from March to August 2012. It was commissioned bythe hospital transfusion committee and had three specificobjectives: 1) to ascertain the motivation for FRDs, 2) todetermine the attitude and knowledge of replacementdonors before giving blood, and 3) to determine their atti-tude and knowledge about blood donation after givingblood. A questionnaire was designed as a data collectiontool to obtain information from family blood donors. Thequestionnaire included 25 questions plus a socioculturalbackground including age, sex, occupation, marital status,and religion. Most questions were multiple choice endingby: “other, please specify.” The first section included 12questions identifying the circumstances of the donor’svisit to the hospital such as how, by whom, and using whatarguments he or she was recruited for blood donation.The last two questions asked about receiving an incentiveand if yes, what it was. The second section of seven ques-tions explored the donor’s experience of donating blood.The last question of this section was open-ended: “Pleaseindicate any thought you may have about the experience.”The third section of six questions examined the possibilityof repeating donation in a context of voluntary blooddonation and, if willing to give blood, where would theypreferably do it.

The questionnaire written in English (the official lan-guage of Ghana) was self-administered after the donationhad been completed and some resting time. Donorsdeferred as not meeting eligibility criteria or reactive withthe predonation viral testing were not included becausethe option of becoming repeat donor was remote and thedisappointment of deferral might influence their willing-ness to participate. Donors were asked if they were willingto spend approximately 15 minutes answering an anony-mous questionnaire regarding their experience as a blooddonor but no formal informed consent was requested tobe signed. The donor’s name was not requested in thequestionnaire for anonymity. Approximately 3% of donorsapproached did not consent to answering the question-naire, arguing a lack of time. The study participants were

ASENSO-MENSAH ET AL.

798 TRANSFUSION Volume 54, March 2014

assisted by two research assistants who were phleboto-mists based at the donor clinic throughout the study. Forparticipants who were illiterate or could not read or writeEnglish (approx. 10%), one of the research assistants ver-bally translated questions in the local language, tickedresponses to multiple-choice questions, or transcribedtranslated answers to the open questions. Data were ana-lyzed by the senior investigator not involved directly indata collection. During the period of availability of theresearch assistants, all eligible successive donors wereapproached but no formal randomization was organized.

RESULTS

The study randomly recruited 513 FDs distributedbetween three-fourths males and one-fourth females.They represented 17.8% of all FDs who gave blood duringthe study period. The sociodemographic data are pre-sented in Table 1. The median age was 27 years and therewas no significant difference in age distribution betweensexes. The vast majority of donors were single (medianage, 23 years) while the median age of those married wassignificantly older (36 years, p < 0.05). The proportionbetween Christians and Muslims was representative of the80/20 ratio in the metropolitan Kumasi area. Notably, thepopulation who consented to answer the questionnaire

was not representative of the general FD population sincethose testing reactive to the viral marker rapid test screen-ing (approx. 15%) who had been excluded from givingblood were not considered. In 2012, the prevalences ofconfirmed test reactivity in FDs for hepatitis B surfaceantigen, anti-HIV, and hepatitis C virus antibody were13.9, 1.4, and 0.9%, respectively.

The largest group of consenting donors was students(median age, 25 years) who, together with teachers, repre-sented more than 50% of the FD population. Nearly allnonstudent donors were employed (98%) in professionsrepresentative of the activities in Kumasi such as wood-work and building, transport, and clothing. Since nearly50% of the population are below age 15 years, the propor-tion of teachers was relatively high (8.6%). The low per-centage of farmers suggests that the population wasessentially originating from the Kumasi urban area(Table 1).

A set of five questions investigated the conditions inwhich the FDs came to the hospital. As shown in Table 2,76% of them had familial ties with a hospitalized patient,whether direct family or with a more extended relation-ship. When there was no familial link to the patient, visi-tors were mostly friends, school, or work mates connectedwith the patient. In Ghana, belonging to a religious com-munity with a well-identified church or mosque is a majorsocial feature and solidarity within such communitiesincludes visiting sick patients or the minister visiting com-munity members and giving blood for them (see Table 1).Only four donors admitted to no connection with thepatient suggesting that the hospital security personnelwere highly effective in banning potential commercialdonors paid by a family.

Visiting the patient was the most frequent purposeand coming to support the patient with food or other typeof care was frequent. However 81 of 483 (16.8%) donorsanswering the question indicated that giving blood wasthe motive of their visiting the hospital. In most cases, therequest for such purpose came from the patient or amember of the family (Table 3). Family membersappeared to be well guided in their choice since more than20% of the donors had given blood before (Table 2).Unfortunately, ambiguity in the formulation of the ques-tion regarding the circumstances of such prior donationprevented from knowing whether it was in the context of afamily or a volunteer donation. The KATH blood servicedoes not have access to a computerized donor registrythat may have provided an answer to this question. Theproportion of prior donation being similar for both stu-dents and teachers compared with the rest of the donorsdoes not suggest that they gave blood in the context ofmobile sessions in schools that represent 60% of volunteerblood collected.10 The popularity in Kumasi of the radiostation partnerships (25% of total volunteer donations)previously described13 may have been another possible

TABLE 1. Population studied*Background All Male Female

SexMale 387 (75.4)Female 126 (24.6)

Age (years)<20 47 (9.5) 30 (8.0) 17 (14.0)20-29 285 (57.6) 213 (57.0) 72 (59.5)30-39 123 (26.9) 103 (27.6) 20 (16.5)40-49 35 (7.0) 23 (6.1) 12 (10.0)�50 5 (1.0) 5 (1.3) 0Median 27 27 26

Marital statusSingle 330 (30.9)Married 148 (68.9)Divorced 1 (0.2)

ReligionChristian 371 (77.6)Muslim 107 (22.4)Other 0

OccupationStudent 209 (45.8) 154 (45.8) 52 (47.3)Teacher 39 (8.6) 25 (7.4) 13 (11.8)Driver 26 (5.7) 21 (6.3) 5 (4.5)Trade or business 38 (8.3) 30 (8.9) 8 (7.3)Building 62 (13.6) 51 (15.2) 9 (8.2)Seamstress 19 (4.2) 10 (3.0) 9 (8.2)Car or metal 17 (3.7) 16 (4.7) 1 (1.0)Farmer 9 (2.0) 6 (1.8) 3 (2.7)Clergy 9 (2.0) 7 (2.1) 2 (1.8)Other 22 (4.8) 13 (3.9) 5 (4.5)Unemployed 6 (1.3) 3 (0.9) 3 (2.7)

* Data are reported as number of donors (%).

INTEGRATING FAMILY DONORS


occasion of volunteer donation but cannot be verified. Aprevious family donation therefore remains a distinct andprobably frequent context for prior donation since noneof the FDs exhibited a donor card systematically given tovolunteer donors.

One of the main objectives of the questionnaire wasto assess the level of pressure to which FDs were allegedlysubmitted. Six questions addressed this issue (Table 3).The patients were the primary persons informing thevisitor that blood was needed, having themselves beeninformed by the ward staff who also provided the informa-tion to the putative visiting donors. In this request orinformation, the blood service was not involved. As aresponse to such requests, most visitors were willing and

the reason attached to the request wasthat the patient needed blood. Approxi-mately one-third of the FDs felt pressureand in all cases it came from the familyindicating that they were searching for adonor(s) and had not been successful(Table 3). In two-thirds of the cases,donors simply agreed to give bloodbecause they were asked (65.4%). Virtu-ally no incentives were involved,whether from the family or the bloodcenter.

As shown in Table 4, no more thanone-third of the donors were afraid ofgiving blood. This proportion was 24.3%among donors who indicated havingdonated blood before, no different fromthe whole surveyed population. Unsur-prisingly, those who had fear were afraidof pain and of the needle as reported forvolunteer donors. Only 35.7% knew,before presenting for donation, thatthey were going to be tested for infec-tions but 62.4% of those having donatedwere interested in the results. Hereagain, the proportion of those knowingabout testing was not greater in thosehaving indicated prior experience ofblood donation. Overall, the experienceof donating blood was satisfactory for76.7% of the donors.

The last five questions of the surveyconcerned the willingness to donateagain as a volunteer donor and possiblybecoming a regular donor. Overwhelm-ingly, donors appeared willing to repeatthe experience of blood donation(98.6%) because they did not think itwas detrimental for their health (91.5%)and regular viral testing was beneficial(93.3%). When exploring what would

motivate these donors to repeat donation, only a minority(31.6%) mentioned altruism (to save lives) but most werecasual about it and, as they responded in the sectionregarding potential pressure, they would give bloodbecause they were asked (51.1%). Some also mentionedconvenience of place of collection as an issue favoringblood donation. This was confirmed in the last questionasking about where they would prefer to give blood. Thelargest number (44.9%) indicated the radio station publicdrives that have become very popular in Kumasi, consis-tent with our previous report that 65% of these donorsrepeated donation spontaneously.13

In summary, this survey brought to light severalimportant issues regarding the potential downsides of

TABLE 2. Circumstances of visit to hospital*Relation to patient

Family 368 (75.9)Direct family (parents, siblings, children) 237 (64.4)Indirect (grandparents, uncle or aunt, spouse) 131 (35.6)

Not family 117 (24.1)Friend 64 (54.7)Same church 14 (12.0)School or work mate 35 (29.9)Do not know the patient 4 (3.4)

Motive of coming to hospitalVisit patient 297 (61.5)Bring food or care 71 (14.7)Donate blood 81 (16.8)Other 34 (7.0)

Prior blood donationYes 107 (20.9)No 406 (79.1)

Prior knowledge patient may need blood 156/501 (31.1)


TABLE 3. Circumstances of blood donationQuestion Optional answers Number (%)

Who informed need of bloodDoctor 140 (27.8)Nurse 131 (26.0)Blood service staff 6 (1.2)Patient 226 (45.0)

Response to asking for bloodWilling 424 (83.5)Reluctant 84 (16.5)

Reasons given to ask for bloodPatient needed blood 480 (93.9)Reduce patient bill 6 (1.2)Hospital blood shortage 3 (0.6)Delay discharge 22 (4.3)

Pressure to donatePatient or family 167 (33.6)

Reason given Other gave, need more 60 (35.9)Failure to find another donor 38 (22.8)Patient may die if no blood 17 (10.2)No answer 52 (31.1)

Just asked 328 (65.4)Incentives

Yes (refreshment) 24 (4.8)No 473 (95.2)



family blood donation and the prospects of repeatingdonation in the volunteer context. First, there was pres-sure to donate from the patient or the family for a minoritybut most gave blood because “they were asked.” Second,the experience of donation was mostly positive and mostdonors considered their undergoing donation to be ben-eficial. Third, nearly all FDs declared their willingness torepeat donation, mostly if they were asked. This is pre-cisely what is done when “volunteer donors” are solicitedto give blood.

DISCUSSION

Recent evidence has been published clearly indicatingthat in several countries of SSA the alleged lower level ofsafety of FRDs compared to first-time volunteer donorswas not substantiated.4-9 These studies led to the conclu-sion that the only policy effectively improving blood safetywas repeat donation.10

To appropriately analyze the data collected in thisstudy, it is critical to place it in a context unusual to FRD inSSA. In the few reports concerning this issue, eitherdonors are replacing the blood transfused to the patientwhen there is some level of blood stock already donated byvolunteer donors or the blood shortage is such that thetransfusion service or hospital requires the donation totreat the patient.14-17 In addition, depending on the situa-tion prevalent in different SSA countries, the donor can be

compensated by the family,16 which makes distinguishingbetween low-safety paid donors and genuine FRD diffi-cult. In Cameroon, for each blood unit prescribed to apatient, the family is asked to provide two donors for col-lection considering the likelihood of one of them beingdeferred or testing positive for an infectious agent.14,16

Clearly, the situation of blood being required from thefamily to treat the patients as well as the less immediatelystressful situation of replacement can place significantburden on the family emotionally and financially. Therelatively unusual situation existing in Kumasi anddescribed in the introduction resulted in that significantpressure, emotional burden on families, and “coercion”tended to be considerably reduced or eliminated as thedata collected suggest.

The demographic and sociologic characteristics ofthe FDs collected here are similar to what was previouslyreported from Kumasi in 2001 and 2009.5,18 However, themedian age was 31 years, older than here (27 years) andthe proportion of female donors increased from 10% in2000 to 12.6% in 2008 and 24.6% here in 2012 (Table 1). Inthe north of Ghana, females were 0.1% of FRDs.19 The dis-tribution of religions between Christian and Muslim wassimilar to what was observed in another group of KumasiFDs examined in 2001 to 2002.20 The spectrum of occupa-tions appeared representative of the Kumasi populationexcept for the virtual absence of unemployed FDs (1.3%).In a representative population of Togolese in Lomé ques-tioned about transfusion, nearly 18% of the intervieweeswere nonemployed in 2003.21 In 2010, the Ghana nationalfigures estimated the unemployment rate for the agerange 17 to 52 at approximately 13% (http://news.moneygh.com/pages/economy/201206/31.php). The FDstherefore appear a particularly active section of thepopulation.

In previous reports regarding FDs in Kumasi, it wasassumed that these donors had not given blood before5

but the answer to Question 1 (Table 2) indicated that21% of FD had donated blood in the past. Informationregarding the circumstances of these prior donationscould not be reliably obtained nor were the results of thetesting that had presumably taken place available. Indi-rect evidence such as the proportion of prior donationsbeing similar irrespective of the occupation of donors(not higher in students and teachers active in schoolswhere most mobile sessions for collecting volunteerblood take place) and the lack of donors presenting adonor card suggest that these previous donations tookplace in a FD situation. This is an indirect indication thatindeed FDs can be repeat donors and this might be oneof the reasons patient and family called upon them.These data might also be taken as supporting theconcept that, in terms of population, FDs and VRNDsare essentially the same but dealt with in differentcircumstances.

TABLE 4. Experience of donating blood*Were you afraid?

Yes 174 (35.7)Reasons for fear

Afraid of pain 95 (57.6)Afraid of needle 53 (32.1)Afraid of losing blood 12 (7.3)Afraid of test results 5 (3.0)

No 334 (66.8)Prior knowledge of tests done

Yes 174 (35.7)No 314 (64.3)

Experience of donatingSatisfactory 367 (72.1)A bit painful 137 (26.9)Very painful 5 (1.0)

Interest in test resultsYes 289 (62.4)No 174 (37.6)

Reception at donor clinicExcellent 94 (18.9)Very good 120 (24.1)Good 215 (43.3)Poor 68 (13.7)

Experience of giving bloodGood and exciting 98 (20.5)Neutral 268 (56.2)Uncomfortable 45 (9.4)Painful 66 (13.8)




http://news.moneygh.com/pages/economy/201206/31.php

http://news.moneygh.com/pages/economy/201206/31.php

The connection between donor and hospitalizedpatient was clearly established and 3.4% of donors admit-ted to not knowing the patient confirming the exclusion ofpaid donors. No further information was available onthese four individuals. The “transactional” aspect of thecompensation expected by the donor whether or not trulyfamily or friend described in north Cameroon was notpresent.16 The matter-of-fact approach to family donationwas clearly seen in answers to the questions regarding thecircumstances of blood donation (Table 3). Either thepatient or the family informed the potential donor beforecoming to the hospital or as a motive to visit the patientthat blood was needed as treatment. Alternatively, once inthe hospital, the staff, doctor, or nurse on the wardinformed the visitor that the patient needed to be trans-fused (93.9%) and asked whether they would agree tomake a donation. As a response to such a request, 83.5% ofdonors were willing, the others being somewhat reluctant.This reluctance admitted by 16.5% of the donors was notsignificantly correlated with pressure felt from the patientor family (38.2% vs. 32.6%). The reasons to incite donorsgiven by families were legitimate, although a few (10.2%)tended to overdramatize the situation by saying that notgiving blood would endanger the patient’s life.

The answers to having received incentives that wereunexpectedly less than 5% of donors indicated havingreceived incentives such as T-shirts, tonic beverages, andso forth that were offered by the blood center, although farfrom systematically. Either the families did not give spe-cific rewards to the donor or the donors did not admit toreceiving any or the question was somewhat misunder-stood. In any case, this result was considerably differentfrom the study in Cameroon where incentives wereexpected, mostly as monetary rewards.16

Despite 16.5% of donors having been reluctant todonate, 72.1% to 76.7% found the experience of donatingblood satisfactory (Table 4). Only 35.7% were aware of thetesting attached to blood donation and this percentagewas similar whether they had donated previously (36.4%)or not (35.1%). After having donated, 62.4% of the donorswere interested in their test results and 93.3% of donorsanswering the question thought that regular testing wouldbe beneficial (Table 5). The response to the prospect ofrepeating donating blood was overwhelmingly positive(98.6%). The motivations for repeating donation wereexpressed by 79% of the respondents and the most fre-quent answer was that “they should be asked” (40.4%), farahead of the altruistic motivation of saving lives (24.9%).Here again the matter-of-fact answers indicated thatgiving blood at a convenient location was important(3.9%) or if health permitted (1.8%). The preferred loca-tion for blood donation was clearly the radio stationpublic drives as previously reported13 rather than at thehospital (Table 5). The choice of the latter location wasunexpectedly frequent but probably influenced by the

good reception at the donor clinic acknowledged by 86.5%of the donors (Table 4).

In the unusual environment created in Kumasi, thepressure or coercion assumed as unacceptable or regret-table by many reports essentially was not observed. Thepatient, the family, or the hospital staff indicated that theblood service was short of blood and asked the visitors togive blood or, in some cases, this request motivated thevisit to the patient. The donors mostly gave blood becausethey were asked and would be willing to repeat donation ifthey were asked (Tables 4 and 5). This is precisely what isrequested from VNRD who are submitted to their own setof pressures such as peer pressure or pressure from theleadership of the school or the religious community10 andmotivated by small gifts and self-satisfaction as much asor more than altruism.22 The main difference between thetwo situations is that FDs are motivated by a personalexperience of a patient needing a blood transfusion and,in the context of a community-oriented culture, providinghelp is in many ways the natural thing to do. In the VNRDsituation, the motivation is less immediate, more intellec-tualized, and more easily modulated by environmentalfactors. It is therefore expected that the rate of positiveresponse in FDs be higher than in VNRDs, although thedata to support such assumptions are not available.

Previous data have demonstrated that the safety offirst-time VNRDs and FRDs was similar4-7 and that repeat-ing donation was the only effective approach to improvingviral safety of donated blood.4,8,23 The assimilation of FRDinto the pool of “volunteer” donors has already been doneand was epidemiologically justified in Brazil where theprevalence of HIV infection was significantly lower in FRD

TABLE 5. Potential for becoming a repeat donor*Would you want to donate again?

Yes 496 (98.6)No 5 (1.0)Not sure 2 (0.4)

Donating again detrimental for health?Yes 43 (8.5)No 465 (91.5)

Would regular testing be beneficial?Yes 470 (93.3)No 34 (8.5)

What would motivate you to repeat? Open answerWhen needed or asked 207 (40.4)When health allows 9 (1.8)To save lives 128 (24.9)Passion 22 (4.3)When at convenient place 20 (3.9)A reward 15 (2.9)Would not repeat donation 4 (0.8)No answer 108 (21.0)

Preferred location of next donationHospital blood service 163 (33.8)Radio station 216 (44.9)Place of worship 57 (11.8)School 46 (9.5)




than in VNRD.24 In Oman, the percentage of FRDs in theblood supply has decreased progressively, in part byrecruiting FRDs into VNRDs and in turning some of theminto repeat donors.25 Outside of SSA, many countries col-lecting more than 10 blood units/1000 inhabitants rely onboth VNRDs and FDs to reach sufficient blood supply andare therefore in a situation similar to Kumasi blood center.This is for instance the case in Tunisia, Saudi Arabia,Lebanon, and Greece.

It is proposed that FDs in Kumasi be considered as athird major source of volunteer donors since they meetall the criteria classically requested of VNRDs of beingvolunteer and nonremunerated, of free will, and of havingbenevolent motivation. It is difficult to accept thatknowing or not knowing the person who is receiving bloodshould make a difference. To the contrary knowingsomeone personally who does need blood should be con-sidered a powerful and perfectly legitimate motivation togive blood and, having done so, to be recruited as repeatdonors. The sections of the Kumasi population contribut-ing blood for patients would then be approximately 50%secondary school students, 25% public drive in radio sta-tions (some from places of worship), and 25% from visi-tors to patients in the hospital. The sum of these threeequally safe populations of volunteer donors combinedprovides sufficient blood and blood products to meet thecurrent clinical demand.

AUTHOR CONTRIBUTIONS

KAM participated in the study design, supervised the study on

site and data analysis, and participated in drafting the

manuscript; GA collected the data and conducted part of the data

analysis; RA administered the questionnaire and translated into

local language when necessary; SOO participated in the study

design and in the drafting of the manuscript; and JPA supervised

the study design and data analysis and wrote the first draft of the

manuscript.

CONFLICT OF INTEREST

None of the authors has any conflict of interest to declare.

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can family or replacement blood donors become regular volunteer donors?

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