INTRODUCTION
Libya's blood transfusion system suffers from chronic blood shortages due to low rates of voluntary, nonremunerated blood donors (VNRBDs).[1] In 2018, VNRBDs represented only 10% of all donations in Libya, family donors accounted for the remainder of donations and women comprised only 1% of donors.[2] The health system has been deeply damaged by the protracted armed conflict in Libya over the last decade.[3] In 2011, a civil war began against the Gaddafi's government, which was followed by an Expansion: Islamic State of Iraq and Syria (ISIS) insurgency, and a second civil war.[4,5] The lack of female participation has narrowed the pool of potential blood donors since women account for 49.5% of Libya's population.[6] Minimal information has been published about Libya's blood transfusion system and blood donation in peer-reviewed journals.[7] The World Health Organization and the Ministry of Health (MoH) have developed technical assessments and documents outlining the key features of the system to bridge these gaps. An assessment of Libya's blood supply system reviewed in a 2015 presentation reiterated the challenges initially described in a 2003 report.[8,9] Understanding the factors which underpin individual willingness to donate blood in a community is essential in creating a dedicated VNRBD base, but most research has only been conducted in higher income countries.[10]
Due to lack of literature in the Libyan context, we identified and analyzed barriers experienced by the community members in becoming VNRBDs. This research will help determine how to engage the community through sensitization and awareness campaigns to increase donation rates and strengthen the national blood supply system.
METHODS
Design, setting, and sampling strategy
Data collection for this mixed methodology study, conducted from July 23, 2020 to September 26, 2020, included a desk review as well as qualitative and quantitative data collection. All participants provided informed consent before participation. Quantitative data were collected to gain insight into the ideal blood donor population through a knowledge, attitudes, and practices (KAP) survey. The sampling frame included community members, aged 18–65 years, and excluded transitory migrant populations. A random walk method was used to select the respondents. The sample aimed to include higher educated individuals, who had at least received some university-level education, since they were more likely to become VNRBDs.[10]
Since population sizes in the areas were unknown, a list of neighborhoods with residents who are more likely to have higher educational status was identified within a 45-min walking radius from the seven blood bank locations. Surveys were conducted at every third house. A pilot was conducted, and the questionnaire was adjusted for suitability before data collection began using KoboCollect.
Qualitative data were collected in-person from regular blood donors through semi-structured interviews to identify factors that lead to blood donation. Key informant interviews (KIIs) were conducted in-person with blood bank managers and individuals with detailed knowledge of the blood donation system to identify the barriers to donor retention. In addition, KIIs were conducted over Skype with academics and international experts. All data were collected in Arabic and translated into English before analysis, except for the KIIs with the academics and international experts which were conducted in English. All qualitative interviews were recorded before being transcribed verbatim and translated into English.
Sample size
The KAP survey provided a cross-sectional perspective from the general population in the following seven cities [Table 1]; 384 surveys were conducted in Tripolitania (distributed equally across Tripoli, Sabratha, and Misrata), 384 surveys in Cyrenaica (distributed equally across Benghazi, Al-Marj, and Tobruk), and 128 surveys in Fezzan (conducted in Sebha).
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Table 1: Knowledge, attitudes, and practices survey conducted in each city
Due to the absence of literature about blood donation in Libya, four interviews were conducted with specialists to inform the data collection tool development process [Table 2].
Table 2: Key informant interviews conducted with specialists
Eleven KIIs were conducted with blood donation experts and heads of the blood banks across the seven cities. In Tripoli, five KIIs were conducted; two with blood bank managers, one with another blood bank employee, one with an employee at the Tripoli University Hospital, while the last KII was with Dr. Gebril, hematologist and adviser of the MoH.
After completing the KAP survey and KIIs, 42 semi-structured interviews were conducted with VNRBDs. Six VNRBDs were chosen randomly from each of the seven blood banks for a total of 42.
Data collection tool and measures
The KAP survey instrument was developed based on a desk review of KAP surveys conducted in the Middle East. Sociodemographic variables included age, sex, marital status, primary language spoken, profession, and highest level of education.
The knowledge and attitude questions assessed the awareness of eligibility, risks, benefits, and the blood donation process. Personal values and attitudes were predominantly asked as open-ended questions. The practices section used a similar structure which assessed experience with blood donation, refusals, and plans to donate blood. The enumerator would then select points mentioned by the participant from a predefined list. All other questions were “yes/no” responses to assess if the participants knew specific blood donation facts [Annexure 1].
KIIs with the blood bank managers assessed experiences of blood donors attending the blood banks, including barriers and motivations, general management of the blood donation process, past campaigns, and donor retention practices.
The 42 semi-structured interviews assessed the motivating factors that encouraged individuals to donate blood. Motivating factors for VNRBDs and each individual's blood donation history were assessed. Ease of accessing donation centers and advocating for blood donation in their communities were also explored.
Data analysis
Quantitative data analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM Inc, Chicago, IL, USA). Descriptive statistics were produced with the KAP survey data.
Thematic analyses were conducted on the qualitative data. Initial themes were used to combine analytical strands from the published literature and the interviews. Coding was standardized to analyze key themes which led to a comparison between theoretical and contextual categories.[11] The coding structure was standardized in MAXQDA.
RESULTS
Sociodemographic characteristics
Table 3 shows the sociodemographic characteristics; 896 participants were included in the survey with a mean age of 31.9 years (standard deviation: 10.1 years), and 51% were women. The marital status was predominantly single (56%), followed by married (38%). A majority (45%) had received their bachelor's degree, and 37% had completed secondary school. Nearly all respondents spoke Arabic (99%) as their primary language.
Table 3: Sample population characteristics
Knowledge regarding blood donation
When asked about the uses of donated blood, the top responses were for surgery (56%), trauma and blood loss (44%), and pregnant women with bleeding complications (29%). Motivations to donate blood were family members or other loved ones (25%) and supporting health systems (23%). When asked whether there is a blood bank in their area, 83% said they are aware of the presence in their city, and 67% were aware of its presence and location. Nearly all respondents (94%) said that they knew their blood type. Only 58% were aware that they could donate blood more than one time per year. In total, 87% of participants indicated that women were eligible to donate blood.
Attitudes toward blood donation
Within the surveyed population, 92% indicated that blood donation is important. When asked about the general beliefs regarding altruism, 93% noted that it is important to support your community through public service or giving, and that it is not necessary to receive an incentive (89%). When asked about how altruism ties into their religious beliefs, 81% said that public service is a part of their religious values. When asked what would motivate blood donation for them, the top three responses were knowing that donated blood would save lives (45%), personal motivations (34%), and the joy of helping others (33%). When asked what may deter individuals from donating blood, respondents said that nondonors had probably just not considered donating (29%), did not have enough information (21%), or lacked personal initiatives (15%).
Practices regarding blood donation
A sizable proportion (39%) said they had donated blood before. Of those, 78% continued donating as a VNRBD, while the other 22% were family/replacement donors. The majority of those who donated (70%) had a good experience; only three (1%), reported a bad experience. Less than a quarter (22%) of blood donors were contacted by the blood bank to see if they would like to donate again. Among those who were contacted, an overwhelming majority (92%) intended to donate again. Of those who had not donated blood (61%), the most frequently cited reason was they merely had not thought about it (37%) or did not have sufficient information. For those who have never donated, 64% had still considered doing so.
Barriers to blood donation, fears, and misinformation
Although more than half of all respondents (64%) said that there were no risks to donate blood, 24% cited fainting as a possibility, and 8% cited the risk of contracting a disease [additional barriers are outlined in Table 4]. Within nondonors, more than half (55%) said that they had considered donating a few times, 36% said that they never considered donating, and 9% said that they considered donating many times.
Table 4: Barriers to blood donation
When asked about the age when individuals become eligible to donate blood, 63% correctly indicated that blood donation eligibility begins at age 18. The two most frequently cited fears were physical harm during blood donation (34%) and how their blood would be used (16%). Additional fears included having blood taken (7%), unclean medical instruments (6%), contracting a blood-borne disease (5%), needles (5%), and fainting (4%). Interviews also revealed that some individuals had trouble accommodating donation hours due to work schedules.
Barriers to blood donation for women
Reservations about appropriateness and misinformation about female eligibility for blood donation were rife in the general population and among blood bank managers. Within the survey respondents, 13% believed that women were not eligible to donate blood. This was evenly expressed by male (53%) and female (47%) respondents. Both men and women believed that women needed permission from their husband to donate blood (83% of men and 73% of women). Blood bank managers cited false information, including that woman could not donate blood because their bodies were weak, they menstruate or lactate, or that they have to remove a hijab before donation.
The blood donation centers do not currently accommodate female donors as there are a few female phlebotomists and no private spaces separate from men for donation. One expert also affirmed that staff have fears about women giving blood which transfers hesitations to women who come to donate. A female donor described support from her husband as integral to her choice to being a VNRBD, but indicated that this was rare in Libya.
Political hesitations
Many managers cited Libya's political crisis and armed conflict as a barrier to donors. Experts indicated that donors have concerns about their physical safety in transit, and that blood donation has become politicized for some prospective donors due to the war. Some respondents (16%) expressed that they would not donate if they knew that their blood would go to people with differing political opinions, while an additional 17% refused to answer this question.
Additional motives observed
Altruistic or religious giving
Most survey participants cited altruism and community support as core values [additional detail is available in Table 5]. Managers emphasized the importance of partnering with mosques during sensitization campaigns because many people look to their imams in their charitable decision-making process. Several interview participants quoted a religious verse that emphasized the link between blood donation and saving lives as effective: “And whoever saves one life, it would be as though he saved the lives of all human beings.”
Table 5: Altruism and religious giving
Personal stories about loved ones who needed blood in an emergency, including stories of rare blood types, were cited as key sensitization moments by some VNRBDs.
Personal health benefits
While this was not cited frequently in the KAP survey, in many semi-structured interviews, managers cited the benefits to their own personal health due to donating blood, including getting their blood checked for diseases and getting a free medical exam. Several VNRBDs described associations with Hijama, a traditional bloodletting and cupping practice known for its health benefits, as one of the reasons they considered blood donation to have health benefits.[12] This practice involves small incisions to the skin and localized suction which allows blood to be drawn from the body. Hijama was advocated for by the Prophet Muhammad in several Hadiths as a health maintenance practice, which is still advocated for in religious settings.[13] While Hijama is not practiced widely, it was mentioned as a key sensitization experience for several VNRBDs.
DISCUSSION
Awareness and educational gaps
Education is strongly correlated with a higher awareness of the uses and importance of donated blood, which in turn correlates with a greater receptivity to sensitization and awareness campaigns.[14] Establishing a robust and sustainable blood supply from a low-risk donor base is most easily obtained among well-educated population.[15] Since 56% of participants had obtained a higher education degree, it is not surprising that most of the populations were able to name a use for donated blood. Understanding the purpose of and processes behind blood donation, including safety protocols, is important for putting donors at ease and establishing trust. Those who are unsure about this information may hesitate to donate blood and may not know if they are eligible. Despite this, most nondonors in the sample showed an interest in donating blood, as 55% of nondonors had considered doing so.
While this relatively high level of awareness and receptivity is positive, one expert emphasized that “in the same way that people know that smoking is bad, people know that blood donation is good.” Like with smoking cessation, blood donation campaigns play an important role in promoting behavior change in nondonors. They play the dual role of encouraging receptive individuals as well as increasing knowledge and reducing hesitancy among those who are uninformed about blood donation to bring them to their first donation experience.[16] In the interviews, experts emphasized the formative nature of the first blood donation experience as having the ability to dispel fears that the donor may have had before donating for the first time.
Barriers to female inclusion
A confluence of misinformation about the female body, social stigma, and concerns about appropriateness represents a huge barrier for women donating blood in Libya. While women have become increasingly active in public life in Libya, crucial social barriers and gender discrimination still hinder gender equality.[17] Misinformation concerning female eligibility to become blood donors, which reflected the broader social barriers experienced by women, was similarly identified in Iran, which like Libya, had nearly no female blood donors in 2005.[18] These lower rates of female participation in Libyan public life are not exclusive to blood donation and have broader implications across the country.[19] One expert interviewed elaborated by say:
“Tradition prevents women from donating blood in the same way that men do. There are obstacles in the community concerning women's movements whether it is going to the Blood Bank or going to the market.”
Awareness campaigns must focus on education concerning female eligibility for the public and blood bank management. Because these centers are important sources of information for the first-time and repeat donors, misinformation coming from staff can influence the beliefs of those who come in to donate, which can then spread through the community. Since there were reservations about women donating on their own and sensitization campaigns must work within the social context in Libya, families could be encouraged to donate together to increase female participation. Blood banks should also adapt to accommodate female donors.
Motivations
Key motivations found in this study, such as motivations to save lives, the relationship between charitable and religious giving, health benefits of blood donation, and the awareness of individual stories about people who benefited from blood donation, are common in KAP surveys about blood donation. The sensitization value of Hijama was an unexpected finding in this study which could be included in campaign strategies and messaging alongside better-known practices like engaging mosques.
Limitations
The sampling strategy to survey individuals with higher levels of education was used to sample the ideal blood donor base, but is not representative of the broader Libyan context. This study was not meant to be nationally representative, but was meant to sample from the ideal blood donor base in key urban settings to design campaigns for the ideal VNRBD population.
CONCLUSION
While there is a high community awareness of blood donation among the study participants, public awareness campaigns could be effective in filling in educational gaps and encouraging the behavior change necessary for strengthening Libya's blood donor base. The surveyed community also reflected a high level of interest in altruistic giving, and many stated that this is an important component of their religious values. Mosques were frequently cited as important sources of information for individuals when they are considering charitable giving. The practice of Hijama is well known across the Islamic world, and campaigns could encourage blood donation by partnering with the Hijama centers. Future campaigns should emphasize the complementary nature of religiously motivated charitable giving and blood donation through partnerships with mosques, Hijama centers, and religious leaders.
Public awareness campaigns must also focus on female eligibility for both the general public and the blood bank staff. Due to the social stigma of women donating, families could be encouraged to donate together to get around concerns about the appropriateness of women donating alone.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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