‘Thank you! please visit us again’. Reflecting on the donor retention literature – implications for retention practices
I. J. T. Veldhuizen, Sanquin Blood Bank Southeast region, PO Box 1013, 6500 BA Nijmegen, The Netherlands
Modern health care depends to a large extent on blood and blood products. Blood is transfused in trauma situations or to patients with blood diseases. Every day hospitals and patients require blood and blood products. Yet, there is always a tension between the hospital demand for blood and the amount of blood that needs to be collected by the various blood organizations. The goal of each blood establishment is to provide enough blood (products) in order to help those in need, but the balance between blood demand and supply is fragile . Most people will not be aware of this steady and ongoing need for blood. Only a small percentage (3–8%) of the eligible population contributes to the blood supply by making donations [2–6]. This means blood establishments are depending upon a small group of volunteers in order to obtain a sufficient amount of blood. Therefore, the act of retaining blood donors is of critical importance to blood organizations . In addition, it has been recognized that blood donated by regular donors is ‘safer’ than blood from first-time donors. Regular donors have lower infectious disease rates than first-time donors who have not previously been screened through the combination of personal questioning about perilous behaviour and disease as well as laboratory testing [8,9]. Focusing on donor retention directly faces blood establishments with the need to examine and understand which factors influence donor return. As already mentioned by Titmuss, ‘It is hard work to maintain repeated and continuous contributions from voluntary donors’.
This paper provides an overview of motivational factors influencing the decision to donate. The impact of negative donation experiences and temporary deferrals on return behaviour is also discussed. The paper concludes by elaborating on and debating about the implications for donor retention practices.
Why give blood? Synopsis of motivational factors
Different motivational factors may impact on the decision to donate. Even the same individual can be multiply motivated and may donate because of more than one reason. So what urges donors to make a donation and to repeat this behaviour from time to time? Insight into this motivational drive is needed to help blood establishments find ways to encourage donors to come back repeatedly. Research has also indicated that the donation experience itself, as well as being temporary deferred, can affect blood donating behaviour and the motivation to return.
Altruistic versus self-regarding motives
Donating blood can be described as a form of pro-social behaviour, a free gift of blood to unnamed strangers. To donate blood implies an altruistic motive, ‘I give blood because I want to help others’. Numerous studies have shown the importance of altruism as a strong motivating factor in donating blood [10–15]. However, at the same time it has also been questioned whether altruism is indeed the most important motivational factor in blood donation. Titmuss already stated that no donor can be said to be characterized by ‘complete, disinterested, spontaneous altruism’ . Wanting to help is an important aspect of the decision to donate, but it is not the only one [12,17,18]. In their study on blood donation as a form of prosocial behaviour, Steele et al.  found that although donors showed high levels of prosocial characteristics, these features were barely related to a high donation frequency. Giving the insignificant influence of prosocial characteristics on donating frequency, they proposed that appealing to the self-interest of and personal benefits for donors might be more beneficial in obtaining more donations. In his review of blood donor motivation, Oswalt  already stated that although altruism is often given as the primary reason for donating, it can be questioned whether this is a true motivation or a rationalization. Some donors indicated feeling proud or feeling like a hero when giving blood. However, acknowledging these feelings is difficult because of the fear of bragging about good deeds. Being ‘selfishly proud’ of donating, conflicts with the ‘more noble motivation of altruism’ . So Oswalt is right to state that the altruism motive may be, at least partially, used as a rationalization, as more self-centred reasons are also important. Studies have shown strong indications that donors partly donate for their own personal benefit. Reciprocal ability, ‘I give blood now, because I might need it myself in the future’ [20,21], and the motivating impact of receiving a health screen are often mentioned [17,18,22–24]. Furthermore, personal needs for recognition and self-esteem are important [7,13,25]. Donating allows people to express personal values and beliefs, like helping the community, and at the same time it allows an enhancement of self-esteem, feeling better about one-self [26–28]. This supports the fact that the desire to help others does not stem from ‘pure’ altruism, as true altruistic deeds are without any expectations of reward. It thus seems that giving blood is partly selfish and ‘might be more an act of benevolence rather than altruism’ . Not only does the recipient profits from his altruistic gift, but also the donor, i.e. feeling good about himself.
So, although altruism is often mentioned as a major reason for donating, donating blood is not a manifestation of pure altruism . In one way or another, donors profit from their gift, either by increased self-esteem or self-satisfaction.
In addition to altruism and more self-regarding motives, other motivational factors also bear importance on the decision to give blood. These factors include awareness of the need for blood , a sense of moral obligation , and convenience (opening hours, donation facility) [7,11,31,32]. A feeling of control or self-efficacy plays a role as well. Donors need to feel up to it, feel confident about the donation experience [33–36].
Donation experience and return behaviour
With regard to donor behaviour, it has been shown that the donation experience itself strongly impacts the motivation to return. Having a bad donation experience is detrimental for making repeated donations. Negative experiences vary from psychological effects (such as fear of the needle, or feeling tense) to physical effects (e.g. nausea, feeling dizzy, being fatigued) and generate donor loss. Fear for a negative donation experience is well known to negatively impact donor return behaviour [24,33,37–41]. Thus, donors who experience a donation reaction are less likely to return to make a subsequent donation, which effects donor retention rates [40,42–44]. Even mild vasovagal reactions reduced return rates by 33% . On the opposite side, a good donation experience is beneficial for donor return behaviour. Donors who indicate to be satisfied with the donation procedure and staff conduct are more likely to make a subsequent donation [18,31,32,45]. Few studies have also pointed to the positive effects, felt after a blood donation, on the well-being of donors. Positive effects may include better mood, higher level of vigilance and feeling calm and relaxed [38,46]. A positive donation experience does serve as a major positive determinant of return behaviour and can last for weeks after the donation has finished [38,47].
Temporary deferrals and return behaviour
Besides the possible effects accompanying a donation, temporary deferral from donating is also known to have a substantial impact on donor return behaviour [41,42,48]. Donor deferrals reduce return rates that generate donor loss [49–51]. Temporarily deferrals may even reduce future return behaviour well beyond the ineligibility deferral period . Most of the reasons for deferral are amended within a few days or weeks. However, receiving a deferral has a powerful impact on donors’ willingness to return to donate. The fact of being deferred is more important than the type of deferral. Even short temporary deferrals have a long-lasting negative influence on donor retention . Temporary deferrals can have the same results as indefinite deferrals. As put forward by Piliavin ‘they provide a permanent excuse for not donating’ .
Implications for retention
What then are the implications for retention when considering the above? Because multiple motivations underpin the motivation to donate blood, retention strategies need to be multifaceted to appeal to a variety of donors. There is a longstanding tradition that recruitment appeals bear strong altruistic messages by conveying the need for blood. For retention strategies conveying the need for blood is important as well. Blood is needed to save lives and by giving blood you can help those in need. However, it is also important to incorporate other messages and strategies. Altruism can be used as a conscious motive that will appeal to most people, because it is a generally accepted drive for blood donation and therefore the one that is most often verbalized . But appealing to altruism alone is not sufficient . The distinction between more altruistic-based motives and self-regarding motives is valuable. However, addressing the notion of self-reward as an important underlying motivation in retention strategies is a delicate matter. Not many donors will admit that they donate, may be partly, for their own personal gain . However, it is important to consider ways to convey the message that donors do not only make a difference but also stress the personal benefits associated with being a donor. Messages and communications with donors could emphasize the affective advantages like enhanced self-esteem and feeling good about ones self [33,53]. Hupfer  even concluded that a blood donation message highlighting self-interest achieved a better result in comparison with stressing the theme of altruism.
In addition, blood establishments also need to convey to their donors a feeling of respect, e.g. donors are valued members of the organization . People show an ‘innate’ need to relate with others, to belong to a group . This social identification with a group generates a sense of psychological attachment [56,57]. Especially when considering volunteer work, studies have shown that it is important that people can derive pride from and receive respect within the organization they are volunteering for [54,58]. Volunteers need to feel respected as a valuable ‘member’ of the organization. Both pride and respect are positively related to the amount of commitment felt .
Bearing in mind these already gained insights, it could be argued that both self-regarding motives and the need for respect appeal to an underlying need in donors, i.e. the need to feel needed. It is important to communicate to donors that their time and effort is greatly appreciated. Acknowledging the fact that donors need to feel needed seems especially important when donors are confronted with a negative donation experience, like being deferred or having a donation reaction. Negative donation experiences harm the donor return rate. Interventions that minimize these reactions could positively influence donor retention. Several studies have shown that some donor reactions can be diminished by simple intervention techniques such as muscle tension and drinking water [59,60]. However, preventing all temporary deferrals and bad donation experiences is impossible. Therefore, it is extremely important for blood establishments to pay attention to the psychological or physical affects accompanying negative donation experiences, as this will contribute to donor retention . Being fearful and nervous for the next donation will invariably impact the donor motivation. Especially when considering the fact that donors do seem to remember more anxiety than they actually had at the time of donation . Receiving support from the blood establishment can attribute to a more satisfying donation experience. Support can be related to the act of donating itself, e.g. by communicating to the donor what to do, or what to expect, when experiencing a donation reaction. Providing information about the prevalence of donation reactions could also be helpful. In addition, blood establishments can provide the donor with more emotion-oriented support, by asking how the donor felt about the negative donation experience and addressing issues of fear and pain. Truthful support, ‘we care about you’, shows that the donor is respected for his endeavours and attributes to the psychological attachment or commitment with the blood establishment, thereby providing better retention . Individuals have certain needs and expectations and when these are met seems an appropriate indicator of their involvement and sustainability . So, even when donors are not able to make a donation, it should be stressed that they still count as valuable members of the donor community. Donors need to feel that they are still in the game, and that they are still needed. A well-known psychological principle is that responses that are immediately reinforced are strengthened . Therefore, conveying the message to donors that they are needed is essential, as it allows for maintenance of their self-esteem, even when their giving was hindered. Feeling needed strongly influences the delicate balance between altruistic and self-regarding motives, and consequently the good habit of continued blood donation.
Donors form the beating heart of each blood establishment. They truly are needed. Because affective and emotional processes play a role in the decision to donate [13,14], the quality of the relationship between the donor and the blood establishment is important in donor retention. Frequent donor appeals ensuring early donor return are important for donor retention, as it allows donors to develop a donor identity and a long-term relationship with the blood establishment . Donors need to perceive this relationship as pleasant, supportive and respectful. This will contribute to the feeling that they do matter and are truly needed, and it creates a sense of impact, competence and meaning. Therefore, a general satisfaction with the donation process itself and with the relationship with the blood establishment will positively contribute to a higher willingness to return as a blood donor .