Evaluating donor recruitment strategies “pure” volunteer recruitment strategies, incentive-based recruitment strategies, and social suasion-based recruitment strategies.
When evaluating the efficacy of different types of donor recruitment strategies, one must consider two important issues: the safety of the donated blood and the adequacy of the supply of blood. These two issues are integrally related. A recruitment strategy that encourages too many individuals to donate-that is, individuals who are at risk for transfusion-transmissible diseases as well as those who are not at risk-will result in a supply of blood that is adequate but unsafe. Conversely, a recruitment strategy that encourages individuals who are not at risk for transfusion-transmissible diseases to donate, but does not motivate a sufficient number of individuals to do so, will result in a supply of blood that is safe but inadequate. The problem, then, is to develop a recruitment strategy that balances these two concerns. Clearly, one area that must be explored in this context is donor motivation-that is, the encouragement of regular donation by individuals who are not at risk. Before 1975, many blood donors in the United States (US)received monetary payment for their blood. However, several studies conducted during the 1970s demonstrated that paid donors were more likely than volunteer donors to be infected with viral hepatitis. As awareness grew that the risk of transfusion-transmitted hepatitis was greater when blood from paid donors was used, a movement began to shift to an all-volunteer system. In 1978, the US Food and Drug Administration required labels on each blood component that specified whether the component was from a paid or volunteer donor. Paid and volunteer donors were defined as follows: “A paid donor is a person who receives monetary payment for a blood donation; a volunteer donor is a person who does not receive monetary payments for a blood donation. Benefits...that are not readily convertible to cash do not constitute monetary payment within the meaning of this paragraph. ”l Despite concerns expressed by some blood bankers that an adequate supply of blood could not be maintained through an all-volunteer system, remunerated blood donation was almost entirely phased out by 1975. While the grimmest predictions of severe blood shortages throughout the country have not been realized since this change to an all-volunteer system, chronic shortages in some geographic areas, and seasonal shortages in others, have emerged.2 In their efforts to maintain an adequate blood supply, blood banking institutions have experimented with a variety of techniques to motivate individuals to donate blood voluntarily. These techniques can be divided into three broad types of donor recruitment strategies:
While all three types of strategies are considered to result in voluntary blood donation, because they do not rely on monetary remuneration, each uses some kind of psychological or material reward (or a combination of the two) to motivate individuals to donate. Pure volunteer recruitment strategies rely most heavily on the internally generated motives of the donors-their sense of altruism or community responsibility. These systems use the communications media to ask people to donate and to stress the positive feelings that blood donation may engender in the donor, but they use little interaction to persuade individuals to donate, and they offer no material incentives or rewards for donating. These strategies rely on messages delivered by media in an impersonal manner, such as radio, television, and print messages. Incentive-based recruitment strategies may also.stress in their media campaigns the pasitive feelings derived from donating blood, but, in addition, they introduce a variety of material rewards to serve as further incentive for donating blood. Some of these material rewards may be tied closely to the long-term donation experiencefor example, commemorative pins or plaques given to the donor who has donated a specified number of gallons of blood. Other rewards are more immediate-for example, T-shirts, mugs, coupons for free goods or services, time off from work, or mini-medical exams for those who donate. Finally, social suasion-based recruitment strategies introduce the encouragement (or pressure) of peers and colleagues to persuade individuals to donate blood. Social suasion-based strategies are often associated with mobile blood drives at the work place, at schools, or at some other site where a group of individuals are united as a social unit. In many cases, the group promises the blood bank a minimum amount of blood if the blood is collected on site by a mobile unit. The pressure on individual members of the group to donate to ensure meeting the promised target may be quite strong and may sometimes have untoward consequences. For example, Doll et al.’ found that 27 percent of the human immunodeficiency virus type l-seropositive donors enrolled in their study felt social pressure to donate. Social suasionbased systems frequently use material incentives to encourage donation, in addition to the social pressure to donate that may be felt in the presence of peers or colleagues.
797
798
EDITORIAL
A second form of the social suasion-based strategy occurs with the use of “directed” donations. In this case, individuals donate blood for a specific transfusion recipient, usually a close friend or relative. Again, the donors may feel a strong pressure to donate as an expression of their caring and concern for the recipient. Each of these types of recruitment strategies has advantages and disadvantages. For example, because pure volunteer recruitment strategies offer no extrinsic rewards to the donors, they are the least likely to attract unsafe donors. On the other hand, with their total reliance on the internally generated motives of the donor, they may not attract sufficient numbers of donors to ensure an adequate blood supply. In contrast, incentivebased systems may attract more donors overall, thus moving closer to the goal of an adequate blood supply, but they may also attract more unsafe donors by encouraging donors to pay more attention to a material reward than to their responsibilities as donors. Finally, social suasion-based systems, like incentive-based systems, may result in an adequate but not necessarily a safe supply of blood. In this case, individuals at risk for transfusion-transmissiblediseases may choose to donate blood rather than to face the exposure and social stigma of being “unsafe.” Adding to the complexities of donor motivation and the maintenance of an adequate and safe blood supply is the fact that various subpopulations of donors may respond differently to different motivational force^.^ For example, several studies cited by Piliavin and Callero4 have found that material rewards encourage donation by persons who have never before donated blood, but that long-term, repeat donors are actually less likely to donate blood when material rewards are offered. The explanation for this seems to be that most long-term, repeat donors have come to identify themselves as altruistic people who donate blood solely to help others. Receiving material rewards makes the act of donating blood feel less altruistic to them and more motivated by selfinterest and greed. These are motivations that contradict their self-image. At the same time, however, most repeat donors do not donate as often as they could, and small incentives that express appreciation to regular donors and enhance their feelings of altruism might effectively encourage more frequent donation. Obviously, much more knowledge is needed about the efficacy of each type of recruitment strategy and the ways in which these strategies interact. Unfortunately, up until now, there has been a dearth of rigorous research on the efficacy of the various recruitment strategies. Recent calls from within the blood banking community for the evaluation of current recruitment strategies speak to the recognition of that One problem confronting those who attempt to evaluate donor recruitment strategies is the lack of control that many local blood centers
TRANSFUSION Vol. 32. No. 9-1992
have over the various recruitment strategies to which their donors are exposed. For example, a local blood center may find it difficult to know how many or which public service announcements about giving blood have appeared in the community.8 (Three organizations produce public service announcements for national distribution: the American Association of Blood Banks, the American Red Cross, and the National Blood Resources Education Program of the National Heart, Lung, and Blood Institute at the National Institutes of Health.) Likewise, a donor recruiter may not be told about the kinds of incentives that donors are being given by an employer. Because it will remain virtually impossible to control all of the variables that might motivate someone to give blood, studies that isolate and manipulate subsets of these variables are critical for understanding what does and does not lead someone to give blood. One such study is reported by Sarason et aL9 in this issue of TRANSFUSION. Sarason et al. show that a videotape based on social learning principles was more successful than current blood center presentations in motivating high school students to give blood for the first time. The videotape was not more successful than current techniques in persuading previous donors to give blood again. It is important that the study reports not only intention to donate, but also actual donation behavior. Case studies of other donor recruitment strategies have been published elsewhere. l 0 ~ l 1 The study by Sarason et al. calls into question one of the common assumptions in donor recruitment, namely, that advertising’s purpose is to sensitize the public to the need for blood. It does not, however, bring people in the door. An advertising campaign based on the same principles as the Sarason videotape might be effective. Granted, there are significant differences between an 11minute videotape presented to a captive audience and a 30-second commercial shown on television during prime time. When the audience is not captive, the message must be captivating. Unless they are working on a pro bono basis, advertising agencies charge a great deal of money to create something captivating. Likewise, unless it is provided pro bono, prime time costs a great deal of money. However, the efficacy of such an advertising approach bears investigating. Two important points emerge from this discussion. First, the definition of a “volunteer” blood donor is problematic. Many donor recruitment strategies that do not include monetary remuneration nonetheless incorporate a variety of motivational forces and externally generated rewards to attract donors. Thus, the distinction between a volunteer donor and a paid donor is not nearly as sharp as the terms suggest. Rather than attempting to refine definitions of what constitutes payment to a blood donor, then, it is more important to examine closely the
TRANSFUSION 1992-Vol. 32. No. 9
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EDITORIAL
motivational forces that underlie any recruitment strategy. The questions to begin with are “How does the strategy motivate individuals to donate?” and “Who is likely to become a donor when this strategy is used?” Second, the question of donor motivation is a complex one that is influenced by social context and cultural milieu. Therefore, when a recruitment strategy is being developed for a given region or group, it is imperative that it be tailored to fit the idiom of the area or group. Recruitment managers must examine the cultural definitions of concepts such as volunteerism, community, and reciprocity before they can begin to develop a donor system that will draw on appropriate and efficacious motivational forces. Donor recruitment strategies that are developed to reflect regional and group differences may appear to be quite different in form, but they will be united by a common, underlying purpose-to maintain a blood supply that is both adequate and safe. Although not yet part of the discourse concerning donor recruitment, one final point deserves mentioning. Those who study the development of altruistic behavior have noted the crucial role of both “nature,” that is, the general cognitive abilities of humans, and “nurture,” that is, the early experiences of human children, in the development of altruistic behavior. As Lieberman states: Children raised in abnormal circumstances do not develop normal general altruistic or social behavior. For example, the children of.. .parents, who are unable to provide a consistent emotional environment, have difficulty in engaging in friendly play with other children, in sharing with their friends, and other aspects of altruistic behavior. Clearly, altruism in the higher human sense is a culturally transmitted behavior that has both a cognitive and an affective base.12 Therefore, the most efficacious long-term donor recruitment strategy may be for blood center staffs to become
more involved in their communities, both as role models of altruistic behavior and as educators of the community’s children.
DONNAJ. MAYO, PHD President Mayo & Associates 717 Sligo Creek Parkway, #201 Takoma Park, MD 20912
References 1. CFR 21 600-799, 1991: paragraph 606.21 (c)(5). 2. Cooper ES. Why America has blood shortages. Bethesda: American Association of Blood Banks, 1992. 3. Doll Is,Pctcrscn LR, While CR, Ward JW, and the HIV Blood Donor Study Group. Human immunodeficiency virus type 1-in-
fecfed blood donors: behavioral characteristics and reasons for donation. Transfusion 1991;31:704-9. 4. Piliavin JA, Caller0 PL. Giving blood: the developmenf of an altruistic identity. Baltimore: The Johns Hopkins University Press, 1991. 5. Dier T, ed. Assessment of blood donor recruitment needs among
6. 7.
8. 9. 10.
members of the Council of Community Blood Centers from the perspectives of recruitment managcrddirectors and senior execufives. Report from the Donor Resources Committee. Washington: Council of Community Blood Centers, April 15, 1991. Summary report: The National Blood Resources Education Program Coordinating Commiftee Meeting. Bethesda, MD: NBREP. May 22, 1992. Solomon J. Blood banking, public relations and the media. AABB News Bricfs 1992;9:3. Yriondo L. Summer ‘91 paid radio campaign pilot test rcport. CCBC Newslefter 1992; July 3:9-10. Sarason IG, Sarason BR. Pierce GR, Sayers MH, Rosenkranz SL. Promotion of high school blood donation: tesfing fhe efficacy of a videotaped intervention. Transfusion 1992;32:818-23. The National Blood Resources Education Program. Together building a blood supply: a guide for donor rccruifment and rctcntion. Berhcsda: National Hearf, Lung, and Blood Institute (NIH).
1990. 11. Parsons V, ed. Donor recruifmenVpublic relations manual. Arlington: American Associalion of Blood Banks, 1990. 12. Lieberman P. Uniquely human: the evolution of speech, thought, and selfless behavior. Cambridge: H a m d University Press, 1991.
When evaluating the efficacy of different types of donor recruitment strategies, one must consider two important issues: the safety of the donated blood and the adequacy of the supply of blood. These two issues are integrally related. A recruitment strategy that encourages too many individuals to donate-that is, individuals who are at risk for transfusion-transmissible diseases as well as those who are not at risk-will result in a supply of blood that is adequate but unsafe. Conversely, a recruitment strategy that encourages individuals who are not at risk for transfusion-transmissible diseases to donate, but does not motivate a sufficient number of individuals to do so, will result in a supply of blood that is safe but inadequate. The problem, then, is to develop a recruitment strategy that balances these two concerns. Clearly, one area that must be explored in this context is donor motivation-that is, the encouragement of regular donation by individuals who are not at risk. Before 1975, many blood donors in the United States (US)received monetary payment for their blood. However, several studies conducted during the 1970s demonstrated that paid donors were more likely than volunteer donors to be infected with viral hepatitis. As awareness grew that the risk of transfusion-transmitted hepatitis was greater when blood from paid donors was used, a movement began to shift to an all-volunteer system. In 1978, the US Food and Drug Administration required labels on each blood component that specified whether the component was from a paid or volunteer donor. Paid and volunteer donors were defined as follows: “A paid donor is a person who receives monetary payment for a blood donation; a volunteer donor is a person who does not receive monetary payments for a blood donation. Benefits...that are not readily convertible to cash do not constitute monetary payment within the meaning of this paragraph. ”l Despite concerns expressed by some blood bankers that an adequate supply of blood could not be maintained through an all-volunteer system, remunerated blood donation was almost entirely phased out by 1975. While the grimmest predictions of severe blood shortages throughout the country have not been realized since this change to an all-volunteer system, chronic shortages in some geographic areas, and seasonal shortages in others, have emerged.2 In their efforts to maintain an adequate blood supply, blood banking institutions have experimented with a variety of techniques to motivate individuals to donate blood voluntarily. These techniques can be divided into three broad types of donor recruitment strategies:
While all three types of strategies are considered to result in voluntary blood donation, because they do not rely on monetary remuneration, each uses some kind of psychological or material reward (or a combination of the two) to motivate individuals to donate. Pure volunteer recruitment strategies rely most heavily on the internally generated motives of the donors-their sense of altruism or community responsibility. These systems use the communications media to ask people to donate and to stress the positive feelings that blood donation may engender in the donor, but they use little interaction to persuade individuals to donate, and they offer no material incentives or rewards for donating. These strategies rely on messages delivered by media in an impersonal manner, such as radio, television, and print messages. Incentive-based recruitment strategies may also.stress in their media campaigns the pasitive feelings derived from donating blood, but, in addition, they introduce a variety of material rewards to serve as further incentive for donating blood. Some of these material rewards may be tied closely to the long-term donation experiencefor example, commemorative pins or plaques given to the donor who has donated a specified number of gallons of blood. Other rewards are more immediate-for example, T-shirts, mugs, coupons for free goods or services, time off from work, or mini-medical exams for those who donate. Finally, social suasion-based recruitment strategies introduce the encouragement (or pressure) of peers and colleagues to persuade individuals to donate blood. Social suasion-based strategies are often associated with mobile blood drives at the work place, at schools, or at some other site where a group of individuals are united as a social unit. In many cases, the group promises the blood bank a minimum amount of blood if the blood is collected on site by a mobile unit. The pressure on individual members of the group to donate to ensure meeting the promised target may be quite strong and may sometimes have untoward consequences. For example, Doll et al.’ found that 27 percent of the human immunodeficiency virus type l-seropositive donors enrolled in their study felt social pressure to donate. Social suasionbased systems frequently use material incentives to encourage donation, in addition to the social pressure to donate that may be felt in the presence of peers or colleagues.
797
798
EDITORIAL
A second form of the social suasion-based strategy occurs with the use of “directed” donations. In this case, individuals donate blood for a specific transfusion recipient, usually a close friend or relative. Again, the donors may feel a strong pressure to donate as an expression of their caring and concern for the recipient. Each of these types of recruitment strategies has advantages and disadvantages. For example, because pure volunteer recruitment strategies offer no extrinsic rewards to the donors, they are the least likely to attract unsafe donors. On the other hand, with their total reliance on the internally generated motives of the donor, they may not attract sufficient numbers of donors to ensure an adequate blood supply. In contrast, incentivebased systems may attract more donors overall, thus moving closer to the goal of an adequate blood supply, but they may also attract more unsafe donors by encouraging donors to pay more attention to a material reward than to their responsibilities as donors. Finally, social suasion-based systems, like incentive-based systems, may result in an adequate but not necessarily a safe supply of blood. In this case, individuals at risk for transfusion-transmissiblediseases may choose to donate blood rather than to face the exposure and social stigma of being “unsafe.” Adding to the complexities of donor motivation and the maintenance of an adequate and safe blood supply is the fact that various subpopulations of donors may respond differently to different motivational force^.^ For example, several studies cited by Piliavin and Callero4 have found that material rewards encourage donation by persons who have never before donated blood, but that long-term, repeat donors are actually less likely to donate blood when material rewards are offered. The explanation for this seems to be that most long-term, repeat donors have come to identify themselves as altruistic people who donate blood solely to help others. Receiving material rewards makes the act of donating blood feel less altruistic to them and more motivated by selfinterest and greed. These are motivations that contradict their self-image. At the same time, however, most repeat donors do not donate as often as they could, and small incentives that express appreciation to regular donors and enhance their feelings of altruism might effectively encourage more frequent donation. Obviously, much more knowledge is needed about the efficacy of each type of recruitment strategy and the ways in which these strategies interact. Unfortunately, up until now, there has been a dearth of rigorous research on the efficacy of the various recruitment strategies. Recent calls from within the blood banking community for the evaluation of current recruitment strategies speak to the recognition of that One problem confronting those who attempt to evaluate donor recruitment strategies is the lack of control that many local blood centers
TRANSFUSION Vol. 32. No. 9-1992
have over the various recruitment strategies to which their donors are exposed. For example, a local blood center may find it difficult to know how many or which public service announcements about giving blood have appeared in the community.8 (Three organizations produce public service announcements for national distribution: the American Association of Blood Banks, the American Red Cross, and the National Blood Resources Education Program of the National Heart, Lung, and Blood Institute at the National Institutes of Health.) Likewise, a donor recruiter may not be told about the kinds of incentives that donors are being given by an employer. Because it will remain virtually impossible to control all of the variables that might motivate someone to give blood, studies that isolate and manipulate subsets of these variables are critical for understanding what does and does not lead someone to give blood. One such study is reported by Sarason et aL9 in this issue of TRANSFUSION. Sarason et al. show that a videotape based on social learning principles was more successful than current blood center presentations in motivating high school students to give blood for the first time. The videotape was not more successful than current techniques in persuading previous donors to give blood again. It is important that the study reports not only intention to donate, but also actual donation behavior. Case studies of other donor recruitment strategies have been published elsewhere. l 0 ~ l 1 The study by Sarason et al. calls into question one of the common assumptions in donor recruitment, namely, that advertising’s purpose is to sensitize the public to the need for blood. It does not, however, bring people in the door. An advertising campaign based on the same principles as the Sarason videotape might be effective. Granted, there are significant differences between an 11minute videotape presented to a captive audience and a 30-second commercial shown on television during prime time. When the audience is not captive, the message must be captivating. Unless they are working on a pro bono basis, advertising agencies charge a great deal of money to create something captivating. Likewise, unless it is provided pro bono, prime time costs a great deal of money. However, the efficacy of such an advertising approach bears investigating. Two important points emerge from this discussion. First, the definition of a “volunteer” blood donor is problematic. Many donor recruitment strategies that do not include monetary remuneration nonetheless incorporate a variety of motivational forces and externally generated rewards to attract donors. Thus, the distinction between a volunteer donor and a paid donor is not nearly as sharp as the terms suggest. Rather than attempting to refine definitions of what constitutes payment to a blood donor, then, it is more important to examine closely the
TRANSFUSION 1992-Vol. 32. No. 9
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EDITORIAL
motivational forces that underlie any recruitment strategy. The questions to begin with are “How does the strategy motivate individuals to donate?” and “Who is likely to become a donor when this strategy is used?” Second, the question of donor motivation is a complex one that is influenced by social context and cultural milieu. Therefore, when a recruitment strategy is being developed for a given region or group, it is imperative that it be tailored to fit the idiom of the area or group. Recruitment managers must examine the cultural definitions of concepts such as volunteerism, community, and reciprocity before they can begin to develop a donor system that will draw on appropriate and efficacious motivational forces. Donor recruitment strategies that are developed to reflect regional and group differences may appear to be quite different in form, but they will be united by a common, underlying purpose-to maintain a blood supply that is both adequate and safe. Although not yet part of the discourse concerning donor recruitment, one final point deserves mentioning. Those who study the development of altruistic behavior have noted the crucial role of both “nature,” that is, the general cognitive abilities of humans, and “nurture,” that is, the early experiences of human children, in the development of altruistic behavior. As Lieberman states: Children raised in abnormal circumstances do not develop normal general altruistic or social behavior. For example, the children of.. .parents, who are unable to provide a consistent emotional environment, have difficulty in engaging in friendly play with other children, in sharing with their friends, and other aspects of altruistic behavior. Clearly, altruism in the higher human sense is a culturally transmitted behavior that has both a cognitive and an affective base.12 Therefore, the most efficacious long-term donor recruitment strategy may be for blood center staffs to become
more involved in their communities, both as role models of altruistic behavior and as educators of the community’s children.
DONNAJ. MAYO, PHD President Mayo & Associates 717 Sligo Creek Parkway, #201 Takoma Park, MD 20912
References 1. CFR 21 600-799, 1991: paragraph 606.21 (c)(5). 2. Cooper ES. Why America has blood shortages. Bethesda: American Association of Blood Banks, 1992. 3. Doll Is,Pctcrscn LR, While CR, Ward JW, and the HIV Blood Donor Study Group. Human immunodeficiency virus type 1-in-
fecfed blood donors: behavioral characteristics and reasons for donation. Transfusion 1991;31:704-9. 4. Piliavin JA, Caller0 PL. Giving blood: the developmenf of an altruistic identity. Baltimore: The Johns Hopkins University Press, 1991. 5. Dier T, ed. Assessment of blood donor recruitment needs among
6. 7.
8. 9. 10.
members of the Council of Community Blood Centers from the perspectives of recruitment managcrddirectors and senior execufives. Report from the Donor Resources Committee. Washington: Council of Community Blood Centers, April 15, 1991. Summary report: The National Blood Resources Education Program Coordinating Commiftee Meeting. Bethesda, MD: NBREP. May 22, 1992. Solomon J. Blood banking, public relations and the media. AABB News Bricfs 1992;9:3. Yriondo L. Summer ‘91 paid radio campaign pilot test rcport. CCBC Newslefter 1992; July 3:9-10. Sarason IG, Sarason BR. Pierce GR, Sayers MH, Rosenkranz SL. Promotion of high school blood donation: tesfing fhe efficacy of a videotaped intervention. Transfusion 1992;32:818-23. The National Blood Resources Education Program. Together building a blood supply: a guide for donor rccruifment and rctcntion. Berhcsda: National Hearf, Lung, and Blood Institute (NIH).
1990. 11. Parsons V, ed. Donor recruifmenVpublic relations manual. Arlington: American Associalion of Blood Banks, 1990. 12. Lieberman P. Uniquely human: the evolution of speech, thought, and selfless behavior. Cambridge: H a m d University Press, 1991.
