Background
Blood products play a vital role in saving lives in a wide variety of medical conditions. Along with the rapid development of the economy and improvement of modern medicine in China, the demand for blood products has continued to grow. Many cities in China have faced a “blood shortage” dilemma, in which the blood supply cannot meet the clinical demand [
1]. Therefore, effective strategies for recruiting sufficient numbers of blood donors are critically needed. It has been widely established that repeat donors have a lower transfusion-transmissible infection risk [
2], and this reduced risk is maintained in donors who have not donated blood for 5 years [
3]. In addition, individuals with a previous donation experience are more likely to restart donations in the future than are first-time donors [
2]. The approach of reactivating inactive donors is nonetheless challenging. The percentage of donations from repeat donors in China was reported to be 34–40% [
4‐
6], which is lower than that in the United States (68%) [
7] and that in England (55%) [
8]. It is essential to determine effective methods for reactivating lapsed donors (defined as those who have made at least one donation within the last 24 months, but not within the previous 12 months) and inactive donors (those who have made at least one donation but have not donated within the previous 24 months) [
9] in order to maintain an adequate blood supply.
The most common and accessible reminders for promoting the return of blood donors include telephone calls, cell phone short message service (SMS) messages, mailings, and e-mails, which may help to support the intrinsic motivations of donors, thereby increasing their commitment to donation [
10]. Aside from its wide availability, low cost, and convenience, SMS messaging has been proven to be an effective intervention for a variety of health behaviours [
11,
12], including blood donation [
13,
14]. Upon receiving SMS message, donors may recall positive feelings from previous blood donations, thus increasing their desire to repeat the experience [
11]. However, instead of sending only generic information via SMS messages, telephone calls have the advantage of personalizing communication with donors. Godin et al. found that a first phone call reminder could encourage first-time donors to return [
15]. Sinclair et al. reported that the use of an adapted motivational interview via telephone calling could increase the chance of future donation [
10]. Donors also reviewed their donation experience in consideration of their wider motivations for giving and extended this line of thinking to problem-solving solutions to perceived barriers [
10].
Eliminating the deterrents for inactive donors is a critical retention strategy. Research has shown that participants are more likely to donate again after they have been invited to report their reasons for not donating [
16]. Reports from different countries have indicated that medical reasons, time constraints, fear (of needles/bleeding), and negative physical reactions are the most frequently self-reported deterrents among lapsed and inactive donors [
17‐
21].
Blood donors report multiple motivations for blood donation [
22‐
26], and campaigns to encourage them to donate should focus on multiple perspectives for different groups. However, in the era of information overload, SMS messaging has the disadvantage of being easily ignored by recipients; hence, the recruitment message needs to be short and simple to understand. Altruistic appeal is a common and acceptable way of recruiting blood donors, which has been widely adopted in various campaigns. Therefore, in the present study, SMS messages with an altruistic appeal that emphasized “saving a life” were sent in an attempt to re-recruit inactive blood donors. Meanwhile, telephone calls were made to re-recruit inactive donors by calling them with not only an altruistic appeal but also questions regarding the reasons why they stopped and providing corresponding solutions.
The objective of this stratified, randomised controlled trials was to assess the efficacy and cost-effectiveness of telephone calls and SMS messages for blood donor re-recruitment. A secondary objective was to explore the self-reported reasons for deferral among donors who received the telephone call. Other aims included evaluating donor return according to demographic characteristics, the time to return among the different interventions, and the cost of telephone calls versus SMS messages to former blood donors.
Discussion
Blood donor retention and re-enrolment are critical for the collection of a sufficient blood supply but are challenges in clinical practice. The use of a stratified, randomised trial design in the present study allowed us to test the efficacy and cost-effectiveness of telephone call and SMS message reminders for prompting inactive blood donors to donate blood again. Altruism, as a genuine part of human nature, has been found to be the most frequent motivator driving people to donate blood [
23‐
25]. In the SMS group, inactive donors received a short text message on their cell phones that contained an altruistic appeal that emphasized how they could “save a life”, and in the telephone group, in addition to the altruistic appeal, inactive donors were also questioned about the reasons why they stopped donating and provided corresponding solutions according to their answers. ITT analysis showed that the differences in the re-donation rates among all participants in the three groups were not statistically significant. ATT estimations revealed that among those who received the interventions successfully, the telephone call was more effective than the SMS reminder or no intervention. Our results also showed that donor reactivation was positively associated with receiving reminders. Moreover, participants in the SMS group returned to donate sooner than control participants (
P = 0.006) within 6 months and based on the calculated ICERs, SMS reminders were more cost-effective than telephone calls. In summary, interventions to promote inactive donors’ return to give blood are appropriate.
As mentioned above, an altruistic (‘save a life’) message was used in the SMS group in this study, because that help-seeking message can evoke empathy, create positive emotional feelings in the reader and connect them to the recipient of their help, which eventually increases helpful behaviour [
34]. Nonetheless, it has been proven that blood donation is driven by multiple motives [
22,
23,
35], and the results of the present study suggest that a message with an altruistic appeal might not be strong enough to prompt action among donors. Gemelli et al. found that sending a personalized post-donation message was effective for retaining donors [
14]. Notably, the SMS messages sent via the Guangzhou Blood Center automatic message sending system are all personalized. After donation each donor receives a message including his/her name, blood type and blood test results confirming their eligibility to donate (donors who are ineligible are informed by phone call). Therefore, the message sent for the purpose of recruiting inactive blood donors becomes personalized if sent via the automatic message sending system, which might increase the re-donation rate. Moreover, male donors or those with a greater past donation frequency were more likely to return after they received a message with an altruistic appeal, and thus, SMS reminders can be used to target these donors. The SMS reminder is overall an effective and convenient strategy for reactivating inactive donors, with the additional advantage of being cost-effective. After the study period, SMS messages were also sent to those who could not be reached in the telephone group and those in the control group.
Although the successful contact rate for the telephone group was much lower than that for the SMS group, the donors in the telephone group were more likely to return once they received the call successfully. Moreover, the effect was greater on those with a higher past donation frequency and older donors. Previous studies proved that the number of previous returns of a donor is positively associated with future return [
6]. As more donations are made, the perception of oneself as a donor becomes internalized and serves as a motivating force for repeat donation [
36]. Blood donors who gave more than 4 donations a year considered blood donation as an act of altruism and promised to continue donating blood in the absence of benefits and rewards [
37]. Therefore, altruistic appeal, by either telephone or SMS reminder, was effective for these donors.
In this study, we not only used an altruistic appeal but also communicated with the donors to better understand their self-reported reasons for blood donation deferral. The altruistic appeal via the telephone call had a significantly greater positive effect on those who reported time constraints than on those who claimed other deterrents kept them from donating again, and in multiple studies, time constraints were the most frequently stated factor preventing donors from continuing to donate blood [
21,
38,
39]. One study found that people believed that spending time on blood donation had no more or less value than any other moment in their day [
17]. They might have a positive attitude towards a request for blood donation, but did not take corresponding action due to a lack of urgency or motivation [
40]. When we mentioned the idea of “saving a life” to emphasize the urgency of the need as well as revisit their original motivation for donating, they returned to donate. Therefore, blood donation agencies should make efforts to minimize the time required for donation, to implement more extensive and flexible opening hours, and also to convince donors of the importance of donation.
An altruistic appeal could not effectively reactivate those who reported medical reasons for their donation deferral. Self-perceived inadequate health status, adverse reaction to blood donation, and becoming unhealthy after blood donation represented particular barriers to blood donation and seem to have similarities in China and other countries. In the Chinese traditional culture, people believe that blood is vital to human life (the Mother of Qi) and loss of blood equates to ruining one’s constitution [
41]. Once donors experience adverse events or even they simply feel tired after donation, they likely deem that they experienced substantial detrimental effects or long-term consequences from blood donation. In addition, some donors may have mentioned medical barriers as a “false” reason that is more socially acceptable than stating that they do not have time [
38]. To develop a strategy to recruit these donors, more specific psychological research should be carried out.
Blood donors in China typically fit into one of two types: those who spontaneously donate at blood collection sites, and those who donate through a group donation. State-owned and state-run enterprises and governmental agencies will compensate workers with either subsidies (small amounts of money for nutritional supplementation) or a few days off (with or without paid vacation), and hence, some groups will limit the number of donors. In light of these findings, the objectives of group donors for blood donation might include a combination of motives, such as modestly self-serving incentives, instead of pure altruism. In addition, with the convenience of the donation process occurring at ones’ place of work, donors do not perceive blood donation as time-consuming or something that must be done too far away. According to these factors, individuals rarely donate again at blood collection sites, if their group stops organizing a blood donation activity or has no quota. In the present study, most group donors refused to donate at blood collection sites because they thought it too inconvenient, but they would donate again at their group.
Our study has some limitations. First, we only used an altruistic appeal in the SMS group, and altruism might not be the main driver for blood donation. Further research using different messages to re-recruit donors is needed to determine which type of message is the optimal intervention. Secondly, telephone and SMS reminders are different interventions, and thus, we cannot determine precisely which factor prompted the donors to return. Future research that explores how inactive donors interact with the interventions is needed to determine which factor is more effective. Moreover, even with delivery confirmation receipts, as available in newer smartphones, one cannot know with certainty that messages were read and understood. In addition, just as we mentioned above, donation records from outside of Guangzhou could not be confirmed. Therefore, the donation frequency history for inactive donors might not be correct, and the re-donation rate, especially for those who cited moving out of Guangzhou as a deterrent, might be underestimated. Those who donated blood outside Guangzhou were cases lost to attrition, but in this randomised controlled trial, the attrition rates among the three groups were believed to be nearly equal. The response rate of telephone group was low (40%), but since the rate at which lapsed blood donors answered telephone interviews from Guangzhou Blood Center was 35–45% [
27], the response rate in the present study was close to the real percentage.
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