SUPPLEMENT ARTICLE The influence of acculturation, medical mistrust, and perceived discrimination on knowledge about blood donation and blood donation status Andre M.N. Renzaho1,2 and Michael J. Polonsky3
INTRODUCTION AIM: The aim of this research was to assess whether perceived discrimination, the level of acculturation, and medical mistrust are associated with knowledge about blood donation processes and blood donation status. METHODS: This cross-sectional study involved 425 African migrants recruited in Melbourne and Adelaide, Australia. Participants were surveyed face-to-face using bilingual workers to maximize the inclusion across different levels of literacy in the community. RESULTS: In the adjusted model, the scores for knowledge about blood donation were positively associated with a longer stay in Australia (β = 0.12, p = 0.001), significantly higher among those with a tertiary education (β = 0.75; p = 0.049), those who came from rural areas (β = 1.54, p = 0.015), and Christians (β = 1.83, p < 0.01) but significantly lower among those from the western African region (β = −1.10, p = 0.032). Scores for knowledge about blood donation were lower among those who were marginalized (β = −1.01, p = 0.026). Medical mistrust and perceived discrimination were not associated with knowledge about blood donation. Participants who were traditionally orientated were 69% less likely to have ever given blood than those who were bicultural or integrated (odds ratio [OR]: 0.31, p = 0.044), whereas the effects of perceived discrimination and medical mistrust were not significant. We also examined whether to restrict the analysis to those who had given blood in Australia postmigration and found that the level of acculturation and medical mistrust were not significant but that perceived discrimination, especially personal discrimination, mattered (OR = 0.63, p = 0.005). CONCLUSION: Efforts to increase blood donation among African migrants need to address the issues related to perceived personal discrimination as an important intervention target.
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Shortages of donated blood products constitute a public health challenge in Australia1 and other developed countries. The various marketing strategies to recruit blood donors have been geared toward promoting voluntary blood donation, which is preferred over other methods of sourcing blood supplies and products (such as replacement donation or compensating donors).2 Despite efforts to attract new donors, blood donation rates remain low in most developed countries, ranging from only 3.5%1 in Australia to only 4% in the UK.3 With one in three Australians predicted to need blood products during their life,4 studies identifying ways to overcome barriers to blood donation are urgently needed. The degree to which donation occurs within communities varies based on a range of demographic factors, with research in Australia and elsewhere suggesting that ethnic communities have lower rates of blood donation.1,5 The issue of ensuring members of all communities donate is important in multicultural countries such as Australia, where the 2011 census suggests that 26% of the Australian population was born overseas and a further 20% had at least one overseasborn parent.6
From the 1Migration, Social Disadvantage, and Health Programs, Global Health and Society Unit, Department of Epidemiology & Preventive Medicine, Monash University, and 2 Burnet Institute, Melbourne, Vic, Australia; and 3School of Management and Marketing, Deakin University, Burwood, Vic, Australia. Address reprint requests to: Andre M.N. Renzaho, Migration, Social Disadvantage, and Health Programs, Global Health and Society Unit, Department of Epidemiology & Preventive Medicine, Monash University, Level 3, Burnet Building, 89 Commercial Rd, Melbourne, Vic 3004, Australia. e-mail: [email protected]. doi: 10.1111/trf.12476 TRANSFUSION 2013;53:162S-171S.
ACCULTURATION AND BLOOD DONATION
Although there has always been high migration to Australia, the distribution has changed significantly. For example, in 1947, 78.7% of migrants to Australia were from the UK, shrinking to 17.4% in 2007-2008. In contrast, in 2006, more than half of all migrants to Australia were from Asia.6 Sub-Saharan African migrants (excluding whites from Zimbabwe and South Africa) only really started arriving in Australia in the late 1990s7; as such there are few adult second-generation African migrants in Australia. Between July 2010 and June 2011, more than 10% of all Australian migrants were from Sub-Saharan African countries.8 The majority of African migrants arrive as refugees under the Refugee and Humanitarian Entrants scheme.7 This has also had a flow on effect of others arriving as part of the family reunion scheme, for example, 42% of Ethiopian migrants and 48% of migrants from the Sudan in 2010-2011 arrived under this category.9 The Australian federal government provides economic, social, and educational support to help refugees acclimatize.10 This is in addition to the many nonprofit organization support programs for refugees.11 Despite the access to a range of government-funded programs, integration of Sub-Saharan migrants and refugees has not always gone smoothly in Australia,12,13 and this feeling of social exclusion affects negatively their blood donation behaviors.14 Indeed, new migrants to Australia and other countries have been found to have even lower donation rates, which is a pressing issue for countries accepting migrants, especially where migrants have unique blood needs that cannot be met within the host community.5 Of course, participation in blood donation may faciliate broader social inclusion,14 which could assist in overcoming some of the issues of social isolation that have been identified to have negative social impacts, for example, as occurred in the French race riots of 200515 and England in the 1980s/1990s.16 As such, cultural diversity brings with it public health challenges with respect to blood donation17 and other health issues.18 Various studies have reported that migrants from low- and middleincome countries to industrialized countries have an increased need for blood products and higher levels of blood transfusions than the host population due to premigration hemoglobinopathies.14,19,20 One of the most affected migrant populations with a high need for blood products is African migrants, a fast-growing migrant population in Organisation for Economic Co-operation and Development countries representing 13% of immigrants from nonmember countries.21 They have one of the highest rates of glucose-6-phosphate dehydrogenase deficiency, in which red blood cell function becomes abnormal, leading to hemolytic anemia resulting from exposure to certain medications, foods, and infections.22 Ironically, in Australia, the Blood Service excludes potential donors with glucose-6-phosphate dehydrogenase deficiency from becoming blood donors, even though other coun-
tries do not exclude such potential donors. Therefore, sourcing blood for such communites within countries accepting these migrants is especially problematic and it is important to understand the factors impacting on donation intentions of Sub-Saharan African migrants in host countries such as Australia. Preexisting home country views about blood and blood donation may also impede African migrants from becoming blood donors.5,23,24 These barriers are further complicated by poor health literacy and knowledge about blood donation.25 Therefore, peoples’ knowledge and awareness of issues associated with blood donation influence their blood donation decisions. Those who donate blood are generally significantly more knowledgeable about blood donation processes than those who do not.25 Factors associated with knowledge about blood donation include religion, premigration area of residence, country of birth, length of stay in Australia, and previous blood donation status.25 Many studies to date have focused on the influence of demographic and economic factors, such as age and socioeconomic disadavantages on blood donation;25 however, the influence of sociocultural factors remains poorly understood. Sociocultural practices, cultural beliefs, and values all have the ability to influence blood donation decisions.26 Researchers examining the sociocultural aspects of blood donation among migrant populations have focused on cultural construction of and cultural norms related to blood donation.5,14,20 Studies examining other sociocultural aspects of blood donation such as the influence of acculturation, perceptions of discrimination in the host community, and migrants’ levels of medical mistrust are lacking. These factors might be expected to be important, especially if they result in less understanding and participation in blood donation processes by migrants in their adopted countries. Acculturation is the change that occurs in cultural groups when two or more cultures come into contact with one another.27 Marginalization (i.e., low levels of both host and home country cultural orientation) and assimilation (i.e., high levels of host and low levels of home country cultural orientation) have been shown to be associated with deleterious health outcomes when compared with integration (i.e., high levels of both host and home country cultural orientation) and traditional (i.e., high levels of host and low levels of home country cultural orientation).28 However, the relationship between the level of acculturation and blood donation has generally not been examined, although it is well documented that perceived discrimination and mistrust of the health system will impede potential migrant donors’ participation in community activities.26 For example, Alden and Cheung26 found that Asian Americans were less likely to donate organs and that they also trusted their doctors less (which is one form of medical mistrust). Volume 53, December 2013 Supplement TRANSFUSION
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Overall, the impacts of perceived discrimination and medical mistrust on blood donation status are poorly understood. Most studies on medical trust have focused on the doctor–patient relationships and found that patients were more trusting of doctors of their own race, rather than on how trust in the health system affects wider health behaviors like blood.29 One exception is Boulware et al.30 who, in a multiethnic study in the United States examining disparities in donor behavior, found that black participants had a greater fear and lack of trust with hospitals, which then translated into a lower blood donation behavior and intentions. However, Brandon, Isaac, and LaVeist31 found that African Americans were generally more mistrsustful of the medical system and believed that ethical abuses such as occurred during Tuskegee experiments could reoccur. Other research has found that levels of trust impact on whether people would donate blood or tissue samples for research, i.e., less trust resulted in less donations.32 It has been found that those who trust the health system and hospitals tend to have more knowledge of the blood supply, less fear of donation, and are more likely to respond to the blood needs of the community than those who do not trust the health system.30,33,34 For African migrants, there may be multiple factors leading to mistrust of the health system, arising from experiences both in their home country such as governmental prosecution,35 mistreatment within the health system,36 or perceptions that they have been treated differently within the health system in host countries because they are African migrants.14 Although there have not been previous studies on medical mistrust and blood donation among Sub-Saharan African migrants, studies looking at this issue generally tend to focus on current and previous donors and do not control for knowledge about blood donation processess. Excluding knowledge about blood donation is important, as knowledge is the framework in which potential donors assess donation decisions. Thus, low levels of information may result in different decisions than if the potential donor had had higher levels of knowledge. The purpose of this research is to address this gap in the knowledge by assessing whether perceived discrimination, the level of acculturation, and medical mistrust are associated with knowledge about blood donation processes and blood donation status. We hypothesize that poor knowledge about blood donation processes and low blood donation rates will be associated with assimilation and marginalization, mistrust of the health system, and perceived discrimination.
METHODS Design, study participants, and sample This cross-sectional study involved interviewing African migrants and refugees aged 16 years and older, living in 164S
TRANSFUSION Volume 53, December 2013 Supplement
Melbourne and Adelaide, Australia. Data were obtained on 483 participants; of these, 58 were excluded because the data were incomplete, had demographic items missing, or were missing more than 5% of the items. Thus, the final sample included 425 participants. The details of the sampling methods have been described elsewhere.37 Briefly, participants were recruited using a purposeful sampling technique through bilingual workers from within the African migrant and refugee communities. The choice of this sampling technique was appropriate and considered necessary to yield a representative sample, because African migrants are difficult-to-access populations and some have low literacy requiring face-to-face surveying. To limit potential sampling bias, sampling was organized by local government areas with high concentrations of African migrants and refugees to ensure inclusiveness and adequate coverage of the target population while also covering the range of communities represented in targeted areas. In each area, English and Arabic leaflets and posters were distributed to African community associations, social service providers, and religious institutions. Those interested in participating contacted the researchers to express an interest and to organize a time with a bilingual worker to administer the survey. Community bilingual workers also sought to organize interviews with members of the community. Data were collected using face-to-face interviews, and each study participant was provided with a $15 gift voucher for participating. The study was approved by the human research ethics committee from the Australian Red Cross Blood Service and Deakin University. All bilingual workers were themselves recruited from within their respective communities. They were provided with training covering interview techniques, data quality, data recording, and ethical issues. They followed a standardized protocol, supported by a training manual for reference while in the field. There were two rounds of interview practice to maximize familiarity and compliance with the issues covered during training and documented in the training manual. Because bilingual workers administered the questionnaire in English, Arabic, or appropriate home country languages, the training in interview techniques emphasized the need for functional equivalence of the concepts across languages. The project was overseen by the African Review Panel, which is a lay person steering committee of community leaders established to advise on effective community mobilization strategies and data collection. Within the study, there were no exclusion criteria based on respondents’ elegibility to donate. Given the low level of knowledge of the blood donation process within Australia within the African community,25 it was assumed that most migrants would not know whether they were elegible to donate or not, based on past medical grounds. Although in some countries, such as the United States,
ACCULTURATION AND BLOOD DONATION
having visited or being from some areas in Africa results in a 3-year blood donation deferral; this is not the case within Australia (although there is a 4-month deferral for having visited malaria endemic countries).38
•
Study variables Dependent variables The study included two dependent variables: knowledge about blood donation processes and blood donation status. Knowledge about blood donation processes was measured using a 16-item objective knowledge scale. It was found to have very good psychometric properties, with a Flesch reading ease of 64·7, an overall item difficulty score of 0.42, an overall point-biserial correlation of 0·38, and an overall Kuder-Richardson-20 reliability coefficient of 0·7833.37 Blood donation status was assessed by the following item: Have you ever donated blood? If yes, in which country have you donated blood?
Independent variables Medical mistrust The medical mistrust construct was adopted from LaVeist, Nickerson, and Bowie’s39 seven statements related to medical mistrust, answered on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Thus, a low score indicates trust in the healthcare system and a high score indicates mistrust in the healthcare system. The statements were: 1) Healthcare organizations have sometimes done harmful experiments on patients without their knowledge; 2) mistakes are common in healthcare organizations; 3) healthcare organizations do not always keep your information totally private; 4) patients have sometimes been deceived or misled by healthcare organizations; 5) sometimes I wonder if healthcare organizations really know what they are doing; 6) when healthcare organizations make mistakes, they usually cover it up; and 7) you would better be cautious when dealing with healthcare organizations. In this study, the scale had high internal consistency (Cronbach’s alpha = 0.83).
Perceived discrimination Perceived discrimination was developed based on items proposed by Phinney et al.40 and Verkuyten;41 and all items were answered on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). A confirmatory factor analysis identified that there were three subscales. The subscales and their respective items and Cronbach’s alpha were: •
Personal discrimination (α = 0.87): 1) I am discriminated against by my fellow students/work colleagues because I have an African background; 2) I am discriminated against by people outside school/work because I have an African background; 3) I am dis-
•
criminated against by my teachers/employer because I have an African background; and 4) I feel that I am not wanted in Australian society. Societal discrimination (α = 0.83): 1) People of African background are called names at work/school because of their African background; 2) people of African background are teased at work/school because of their African background; and 3) people with an African background are discriminated against within the community. Exclusion/not fitting in (α = 0.92): 1) It is not very easy for me to participate in group activities (hobbies, sport) with people from non-African backgrounds; 2) it is not very easy for me to make friends with people from non-African backgrounds; and 3) it is not very easy for me to talk with people from non-African backgrounds in my break at work/school.
Acculturation The Vancouver Index of Acculturation scale was used, which has been validated in a number of studies.24,25 The index is comprised of two components: 10 items are related to home culture (i.e., African) and 10 items are related to the host culture (i.e., Australian). The questions were answered on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), and the two cultural dimensions had good internal consistency, with a Cronbach’s alpha of 0.87 for African orientation and 0.82 for Australian orientation. A median split was used for each dimension42 allowing respondents to be categorized into one of four groups:43 traditional or separation (high African-low Australian), assimilated (high Australian-low African), integrated or bicultural (high on both), and marginalized (low on both).
Demographic and socioeconomic factors Demographic characteristics included sex (female, male), age, and length of stay in Australia in years, religion (Muslim, Christian, other), migration status (refugees, family sponsored/reunion, other), educational attainment (secondary or less, tertiary/TAFE), employment (unemployed, some employment, other), area lived in before migration (refugee camp, large city/town, village), and African region of birth based on country of birth (central, eastern, western, southern). The distribution of demographic factors within the study is reported in Table 1A. Unfortunately, there is not broad-based statistics comparing the African migrant community to the general population. The distribution in regard to sex is, however, very similar (49.5% male African migrants, 49.7% male Australian community). The general community in Australia has larger younger segments (18.9%-11.6%, 0-14 years) and a greater percentage of older community members (25.3%-19.1%, 55+ years) but fewer middle aged Volume 53, December 2013 Supplement TRANSFUSION
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TABLE 1A. Demographic and socioeconomic variables by knowledge about blood donation processes and blood donation status Characteristics All Age in years 16-24 years 25-44 years ≥45 years Mean (SD) Gender Female Male Length of stay in Australia 5 years or less More than 5 years Mean (SD) Migration status Refugee Family reunion Other Educational attainment Secondary or less Tertiary/TAFE African region of origin Central Africa Eastern Africa Western Africa Southern Africa Area lived in before migration Refugee camp Large city/town Rural/village Religion Muslim Christian Other
N 425
% 100
Knowledge score Mean (SD) p value 6.7 (3.5)
Yes 17.2
Ever given blood No 82.8
7.9 18.3 29.7 8.3 (3.1)
92.1 81.7 70.2 6.5 (3.5)
15.1 18.8
84.9 81.2
p Value
127 224 74 425
29.9 52.7 17.4
6.3 (3.6) 6.8 (3.7) 7.2 (2.9) 32.9 (12.3)
186 239
43.8 56.2
6.7 (3.7) 6.8 (3.4)
234 191 425
55.1 44.9
6.4 (3.5) 7.1 (3.5) 6.5 (5.2)
0.026
19.7 14.1 5.5 (4.1)
80.3 85.9 6.7 (5.4)
0.030
317 80 28
74.6 18.8 6.6
6.6 (3.5) 7.1 (3.5) 7.5 (3.8)
0.222
15.5 16.3 39.3
84.5 83.8 60.7
0.006
239 186
56.2 43.8
6.4 (3.3) 7.1 (3.8)
13.0 22.6
87 77.4
146 159 78 25
35.8 39 19.1 6.1
6.9 (2.8) 7.2 (3.4) 5.6 (4.6) 6.6 (4.1)
10.3 16.4 18.0 52.0
89.7 83.7 82.1 48.0
80 291 53
18.9 68.6 12.5
6.0 (3.4) 6.7 (3.5) 7.8 (3.7)
0.0142
18.8 16.8 17.0
81.3 83.2 83
0.922
98 304 23
23.1 71.5 5.41
5.8 (3.6) 7.0 (3.4) 7.0 (3.8)
0.008
10.2 20.1 8.7
89.8 79.9 91.3
0.043
0.145
0.755
0.030
0.020
INTRODUCTION AIM: The aim of this research was to assess whether perceived discrimination, the level of acculturation, and medical mistrust are associated with knowledge about blood donation processes and blood donation status. METHODS: This cross-sectional study involved 425 African migrants recruited in Melbourne and Adelaide, Australia. Participants were surveyed face-to-face using bilingual workers to maximize the inclusion across different levels of literacy in the community. RESULTS: In the adjusted model, the scores for knowledge about blood donation were positively associated with a longer stay in Australia (β = 0.12, p = 0.001), significantly higher among those with a tertiary education (β = 0.75; p = 0.049), those who came from rural areas (β = 1.54, p = 0.015), and Christians (β = 1.83, p < 0.01) but significantly lower among those from the western African region (β = −1.10, p = 0.032). Scores for knowledge about blood donation were lower among those who were marginalized (β = −1.01, p = 0.026). Medical mistrust and perceived discrimination were not associated with knowledge about blood donation. Participants who were traditionally orientated were 69% less likely to have ever given blood than those who were bicultural or integrated (odds ratio [OR]: 0.31, p = 0.044), whereas the effects of perceived discrimination and medical mistrust were not significant. We also examined whether to restrict the analysis to those who had given blood in Australia postmigration and found that the level of acculturation and medical mistrust were not significant but that perceived discrimination, especially personal discrimination, mattered (OR = 0.63, p = 0.005). CONCLUSION: Efforts to increase blood donation among African migrants need to address the issues related to perceived personal discrimination as an important intervention target.
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Shortages of donated blood products constitute a public health challenge in Australia1 and other developed countries. The various marketing strategies to recruit blood donors have been geared toward promoting voluntary blood donation, which is preferred over other methods of sourcing blood supplies and products (such as replacement donation or compensating donors).2 Despite efforts to attract new donors, blood donation rates remain low in most developed countries, ranging from only 3.5%1 in Australia to only 4% in the UK.3 With one in three Australians predicted to need blood products during their life,4 studies identifying ways to overcome barriers to blood donation are urgently needed. The degree to which donation occurs within communities varies based on a range of demographic factors, with research in Australia and elsewhere suggesting that ethnic communities have lower rates of blood donation.1,5 The issue of ensuring members of all communities donate is important in multicultural countries such as Australia, where the 2011 census suggests that 26% of the Australian population was born overseas and a further 20% had at least one overseasborn parent.6
From the 1Migration, Social Disadvantage, and Health Programs, Global Health and Society Unit, Department of Epidemiology & Preventive Medicine, Monash University, and 2 Burnet Institute, Melbourne, Vic, Australia; and 3School of Management and Marketing, Deakin University, Burwood, Vic, Australia. Address reprint requests to: Andre M.N. Renzaho, Migration, Social Disadvantage, and Health Programs, Global Health and Society Unit, Department of Epidemiology & Preventive Medicine, Monash University, Level 3, Burnet Building, 89 Commercial Rd, Melbourne, Vic 3004, Australia. e-mail: [email protected]. doi: 10.1111/trf.12476 TRANSFUSION 2013;53:162S-171S.
ACCULTURATION AND BLOOD DONATION
Although there has always been high migration to Australia, the distribution has changed significantly. For example, in 1947, 78.7% of migrants to Australia were from the UK, shrinking to 17.4% in 2007-2008. In contrast, in 2006, more than half of all migrants to Australia were from Asia.6 Sub-Saharan African migrants (excluding whites from Zimbabwe and South Africa) only really started arriving in Australia in the late 1990s7; as such there are few adult second-generation African migrants in Australia. Between July 2010 and June 2011, more than 10% of all Australian migrants were from Sub-Saharan African countries.8 The majority of African migrants arrive as refugees under the Refugee and Humanitarian Entrants scheme.7 This has also had a flow on effect of others arriving as part of the family reunion scheme, for example, 42% of Ethiopian migrants and 48% of migrants from the Sudan in 2010-2011 arrived under this category.9 The Australian federal government provides economic, social, and educational support to help refugees acclimatize.10 This is in addition to the many nonprofit organization support programs for refugees.11 Despite the access to a range of government-funded programs, integration of Sub-Saharan migrants and refugees has not always gone smoothly in Australia,12,13 and this feeling of social exclusion affects negatively their blood donation behaviors.14 Indeed, new migrants to Australia and other countries have been found to have even lower donation rates, which is a pressing issue for countries accepting migrants, especially where migrants have unique blood needs that cannot be met within the host community.5 Of course, participation in blood donation may faciliate broader social inclusion,14 which could assist in overcoming some of the issues of social isolation that have been identified to have negative social impacts, for example, as occurred in the French race riots of 200515 and England in the 1980s/1990s.16 As such, cultural diversity brings with it public health challenges with respect to blood donation17 and other health issues.18 Various studies have reported that migrants from low- and middleincome countries to industrialized countries have an increased need for blood products and higher levels of blood transfusions than the host population due to premigration hemoglobinopathies.14,19,20 One of the most affected migrant populations with a high need for blood products is African migrants, a fast-growing migrant population in Organisation for Economic Co-operation and Development countries representing 13% of immigrants from nonmember countries.21 They have one of the highest rates of glucose-6-phosphate dehydrogenase deficiency, in which red blood cell function becomes abnormal, leading to hemolytic anemia resulting from exposure to certain medications, foods, and infections.22 Ironically, in Australia, the Blood Service excludes potential donors with glucose-6-phosphate dehydrogenase deficiency from becoming blood donors, even though other coun-
tries do not exclude such potential donors. Therefore, sourcing blood for such communites within countries accepting these migrants is especially problematic and it is important to understand the factors impacting on donation intentions of Sub-Saharan African migrants in host countries such as Australia. Preexisting home country views about blood and blood donation may also impede African migrants from becoming blood donors.5,23,24 These barriers are further complicated by poor health literacy and knowledge about blood donation.25 Therefore, peoples’ knowledge and awareness of issues associated with blood donation influence their blood donation decisions. Those who donate blood are generally significantly more knowledgeable about blood donation processes than those who do not.25 Factors associated with knowledge about blood donation include religion, premigration area of residence, country of birth, length of stay in Australia, and previous blood donation status.25 Many studies to date have focused on the influence of demographic and economic factors, such as age and socioeconomic disadavantages on blood donation;25 however, the influence of sociocultural factors remains poorly understood. Sociocultural practices, cultural beliefs, and values all have the ability to influence blood donation decisions.26 Researchers examining the sociocultural aspects of blood donation among migrant populations have focused on cultural construction of and cultural norms related to blood donation.5,14,20 Studies examining other sociocultural aspects of blood donation such as the influence of acculturation, perceptions of discrimination in the host community, and migrants’ levels of medical mistrust are lacking. These factors might be expected to be important, especially if they result in less understanding and participation in blood donation processes by migrants in their adopted countries. Acculturation is the change that occurs in cultural groups when two or more cultures come into contact with one another.27 Marginalization (i.e., low levels of both host and home country cultural orientation) and assimilation (i.e., high levels of host and low levels of home country cultural orientation) have been shown to be associated with deleterious health outcomes when compared with integration (i.e., high levels of both host and home country cultural orientation) and traditional (i.e., high levels of host and low levels of home country cultural orientation).28 However, the relationship between the level of acculturation and blood donation has generally not been examined, although it is well documented that perceived discrimination and mistrust of the health system will impede potential migrant donors’ participation in community activities.26 For example, Alden and Cheung26 found that Asian Americans were less likely to donate organs and that they also trusted their doctors less (which is one form of medical mistrust). Volume 53, December 2013 Supplement TRANSFUSION
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RENZAHO AND POLONSKY
Overall, the impacts of perceived discrimination and medical mistrust on blood donation status are poorly understood. Most studies on medical trust have focused on the doctor–patient relationships and found that patients were more trusting of doctors of their own race, rather than on how trust in the health system affects wider health behaviors like blood.29 One exception is Boulware et al.30 who, in a multiethnic study in the United States examining disparities in donor behavior, found that black participants had a greater fear and lack of trust with hospitals, which then translated into a lower blood donation behavior and intentions. However, Brandon, Isaac, and LaVeist31 found that African Americans were generally more mistrsustful of the medical system and believed that ethical abuses such as occurred during Tuskegee experiments could reoccur. Other research has found that levels of trust impact on whether people would donate blood or tissue samples for research, i.e., less trust resulted in less donations.32 It has been found that those who trust the health system and hospitals tend to have more knowledge of the blood supply, less fear of donation, and are more likely to respond to the blood needs of the community than those who do not trust the health system.30,33,34 For African migrants, there may be multiple factors leading to mistrust of the health system, arising from experiences both in their home country such as governmental prosecution,35 mistreatment within the health system,36 or perceptions that they have been treated differently within the health system in host countries because they are African migrants.14 Although there have not been previous studies on medical mistrust and blood donation among Sub-Saharan African migrants, studies looking at this issue generally tend to focus on current and previous donors and do not control for knowledge about blood donation processess. Excluding knowledge about blood donation is important, as knowledge is the framework in which potential donors assess donation decisions. Thus, low levels of information may result in different decisions than if the potential donor had had higher levels of knowledge. The purpose of this research is to address this gap in the knowledge by assessing whether perceived discrimination, the level of acculturation, and medical mistrust are associated with knowledge about blood donation processes and blood donation status. We hypothesize that poor knowledge about blood donation processes and low blood donation rates will be associated with assimilation and marginalization, mistrust of the health system, and perceived discrimination.
METHODS Design, study participants, and sample This cross-sectional study involved interviewing African migrants and refugees aged 16 years and older, living in 164S
TRANSFUSION Volume 53, December 2013 Supplement
Melbourne and Adelaide, Australia. Data were obtained on 483 participants; of these, 58 were excluded because the data were incomplete, had demographic items missing, or were missing more than 5% of the items. Thus, the final sample included 425 participants. The details of the sampling methods have been described elsewhere.37 Briefly, participants were recruited using a purposeful sampling technique through bilingual workers from within the African migrant and refugee communities. The choice of this sampling technique was appropriate and considered necessary to yield a representative sample, because African migrants are difficult-to-access populations and some have low literacy requiring face-to-face surveying. To limit potential sampling bias, sampling was organized by local government areas with high concentrations of African migrants and refugees to ensure inclusiveness and adequate coverage of the target population while also covering the range of communities represented in targeted areas. In each area, English and Arabic leaflets and posters were distributed to African community associations, social service providers, and religious institutions. Those interested in participating contacted the researchers to express an interest and to organize a time with a bilingual worker to administer the survey. Community bilingual workers also sought to organize interviews with members of the community. Data were collected using face-to-face interviews, and each study participant was provided with a $15 gift voucher for participating. The study was approved by the human research ethics committee from the Australian Red Cross Blood Service and Deakin University. All bilingual workers were themselves recruited from within their respective communities. They were provided with training covering interview techniques, data quality, data recording, and ethical issues. They followed a standardized protocol, supported by a training manual for reference while in the field. There were two rounds of interview practice to maximize familiarity and compliance with the issues covered during training and documented in the training manual. Because bilingual workers administered the questionnaire in English, Arabic, or appropriate home country languages, the training in interview techniques emphasized the need for functional equivalence of the concepts across languages. The project was overseen by the African Review Panel, which is a lay person steering committee of community leaders established to advise on effective community mobilization strategies and data collection. Within the study, there were no exclusion criteria based on respondents’ elegibility to donate. Given the low level of knowledge of the blood donation process within Australia within the African community,25 it was assumed that most migrants would not know whether they were elegible to donate or not, based on past medical grounds. Although in some countries, such as the United States,
ACCULTURATION AND BLOOD DONATION
having visited or being from some areas in Africa results in a 3-year blood donation deferral; this is not the case within Australia (although there is a 4-month deferral for having visited malaria endemic countries).38
•
Study variables Dependent variables The study included two dependent variables: knowledge about blood donation processes and blood donation status. Knowledge about blood donation processes was measured using a 16-item objective knowledge scale. It was found to have very good psychometric properties, with a Flesch reading ease of 64·7, an overall item difficulty score of 0.42, an overall point-biserial correlation of 0·38, and an overall Kuder-Richardson-20 reliability coefficient of 0·7833.37 Blood donation status was assessed by the following item: Have you ever donated blood? If yes, in which country have you donated blood?
Independent variables Medical mistrust The medical mistrust construct was adopted from LaVeist, Nickerson, and Bowie’s39 seven statements related to medical mistrust, answered on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Thus, a low score indicates trust in the healthcare system and a high score indicates mistrust in the healthcare system. The statements were: 1) Healthcare organizations have sometimes done harmful experiments on patients without their knowledge; 2) mistakes are common in healthcare organizations; 3) healthcare organizations do not always keep your information totally private; 4) patients have sometimes been deceived or misled by healthcare organizations; 5) sometimes I wonder if healthcare organizations really know what they are doing; 6) when healthcare organizations make mistakes, they usually cover it up; and 7) you would better be cautious when dealing with healthcare organizations. In this study, the scale had high internal consistency (Cronbach’s alpha = 0.83).
Perceived discrimination Perceived discrimination was developed based on items proposed by Phinney et al.40 and Verkuyten;41 and all items were answered on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). A confirmatory factor analysis identified that there were three subscales. The subscales and their respective items and Cronbach’s alpha were: •
Personal discrimination (α = 0.87): 1) I am discriminated against by my fellow students/work colleagues because I have an African background; 2) I am discriminated against by people outside school/work because I have an African background; 3) I am dis-
•
criminated against by my teachers/employer because I have an African background; and 4) I feel that I am not wanted in Australian society. Societal discrimination (α = 0.83): 1) People of African background are called names at work/school because of their African background; 2) people of African background are teased at work/school because of their African background; and 3) people with an African background are discriminated against within the community. Exclusion/not fitting in (α = 0.92): 1) It is not very easy for me to participate in group activities (hobbies, sport) with people from non-African backgrounds; 2) it is not very easy for me to make friends with people from non-African backgrounds; and 3) it is not very easy for me to talk with people from non-African backgrounds in my break at work/school.
Acculturation The Vancouver Index of Acculturation scale was used, which has been validated in a number of studies.24,25 The index is comprised of two components: 10 items are related to home culture (i.e., African) and 10 items are related to the host culture (i.e., Australian). The questions were answered on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), and the two cultural dimensions had good internal consistency, with a Cronbach’s alpha of 0.87 for African orientation and 0.82 for Australian orientation. A median split was used for each dimension42 allowing respondents to be categorized into one of four groups:43 traditional or separation (high African-low Australian), assimilated (high Australian-low African), integrated or bicultural (high on both), and marginalized (low on both).
Demographic and socioeconomic factors Demographic characteristics included sex (female, male), age, and length of stay in Australia in years, religion (Muslim, Christian, other), migration status (refugees, family sponsored/reunion, other), educational attainment (secondary or less, tertiary/TAFE), employment (unemployed, some employment, other), area lived in before migration (refugee camp, large city/town, village), and African region of birth based on country of birth (central, eastern, western, southern). The distribution of demographic factors within the study is reported in Table 1A. Unfortunately, there is not broad-based statistics comparing the African migrant community to the general population. The distribution in regard to sex is, however, very similar (49.5% male African migrants, 49.7% male Australian community). The general community in Australia has larger younger segments (18.9%-11.6%, 0-14 years) and a greater percentage of older community members (25.3%-19.1%, 55+ years) but fewer middle aged Volume 53, December 2013 Supplement TRANSFUSION
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TABLE 1A. Demographic and socioeconomic variables by knowledge about blood donation processes and blood donation status Characteristics All Age in years 16-24 years 25-44 years ≥45 years Mean (SD) Gender Female Male Length of stay in Australia 5 years or less More than 5 years Mean (SD) Migration status Refugee Family reunion Other Educational attainment Secondary or less Tertiary/TAFE African region of origin Central Africa Eastern Africa Western Africa Southern Africa Area lived in before migration Refugee camp Large city/town Rural/village Religion Muslim Christian Other
N 425
% 100
Knowledge score Mean (SD) p value 6.7 (3.5)
Yes 17.2
Ever given blood No 82.8
7.9 18.3 29.7 8.3 (3.1)
92.1 81.7 70.2 6.5 (3.5)
15.1 18.8
84.9 81.2
p Value
127 224 74 425
29.9 52.7 17.4
6.3 (3.6) 6.8 (3.7) 7.2 (2.9) 32.9 (12.3)
186 239
43.8 56.2
6.7 (3.7) 6.8 (3.4)
234 191 425
55.1 44.9
6.4 (3.5) 7.1 (3.5) 6.5 (5.2)
0.026
19.7 14.1 5.5 (4.1)
80.3 85.9 6.7 (5.4)
0.030
317 80 28
74.6 18.8 6.6
6.6 (3.5) 7.1 (3.5) 7.5 (3.8)
0.222
15.5 16.3 39.3
84.5 83.8 60.7
0.006
239 186
56.2 43.8
6.4 (3.3) 7.1 (3.8)
13.0 22.6
87 77.4
146 159 78 25
35.8 39 19.1 6.1
6.9 (2.8) 7.2 (3.4) 5.6 (4.6) 6.6 (4.1)
10.3 16.4 18.0 52.0
89.7 83.7 82.1 48.0
80 291 53
18.9 68.6 12.5
6.0 (3.4) 6.7 (3.5) 7.8 (3.7)
0.0142
18.8 16.8 17.0
81.3 83.2 83
0.922
98 304 23
23.1 71.5 5.41
5.8 (3.6) 7.0 (3.4) 7.0 (3.8)
0.008
10.2 20.1 8.7
89.8 79.9 91.3
0.043
0.145
0.755
0.030
0.020
