Motivations and deterrents of blood donation among blood donors during the COVID‐19 pandemic in Hong Kong

Abstract Background The COVID‐19 pandemic has resulted in a reduction in blood donations and limited blood supply in many countries. The theory of planned behaviour has been widely used in past studies to understand the factors influencing blood donation. However, this theory limits analyses to the individual level. Furthermore, most research on the determinants of blood donation during the COVID‐19 pandemic is quantitative in nature, with relevant qualitative research being rare. Objectives To investigate the motivators and demotivators for donating blood among current blood donors during COVID‐19 pandemic. Design Forty in‐depth, individual semistructured interviews were conducted with current blood donors from December 2020 to March 2021 in Hong Kong. Thematic content analysis was adopted in the data analysis. Results The majority of the participants (n = 37) were demotivated from donating blood during the COVID‐19 pandemic. Factors at the perceptual, social and institutional levels interacted to cause this reluctance. Only three participants felt more motivated to donate blood. The data revealed that sociocultural forces and government pandemic prevention policies strongly affected the participants' motivations to donate blood during the pandemic. Conclusion This study presents a macro understanding of blood donation behaviour by investigating the institutional, social and perceptual factors influencing current blood donors during the COVID‐19 pandemic. This adds a more comprehensive understanding of blood donation where the theory of planned behaviour is widely used in past studies. Public Contribution The participants shared their experiences in the interviews. Their experiences provide hints for explaining the decreasing blood donation during the pandemic times.


| INTRODUCTION
COVID-19 has posed substantial challenges to maintaining blood supply in numerous areas, [1][2][3] including Hong Kong. This city has faced difficulty in collecting blood during the COVID-19 pandemic. 4 The blood supply has been depleted to a low level that is inadequate for the daily needs of hospitals 5 as the pandemic got worse, from 300 to 400 units of donated blood collected daily since early January 2021, 6 to 200 to 300 units collected daily since the beginning of March 2022 when the fifth wave of outbreak hit Hong Kong. 5 The retention of current blood donors is one method of maintaining the blood supply. Haw et al. 1 suggested that researchers must study how current blood donors have responded to the COVID-19 pandemic and the motivations of their responses in the context of the pandemic, and how blood donors can be retained for continued donation in pandemic times.
In Europe, Africa, Brazil and China, participation in blood donation declined during the COVID-19 pandemic. [7][8][9][10] Studies have found that the fear of contracting COVID-19 is common among blood donors from numerous countries. 4,7,[10][11][12][13] In Cameroon, donors were reluctant to donate blood if adequate safety measures were not in place at donor centres. 13 In Saudi Arabia, people reported that they wanted to avoid contact with other blood donors to minimize their possibility of contracting the virus. 11 Moreover, the adoption of the stay-at-home strategy was prominent for reduced blood donation in some African countries during the pandemic. 14

| Significance
The theory of planned behaviour has been widely used to understand the factors that influence blood donation. [15][16][17][18][19][20][21] However, this theory is limited to the individual level of factors because it focuses on themes such as motives, self-efficacy, anxiety and stress. [22][23][24][25][26][27] Blood donation behaviour should be understood as a multidimensional and nuanced construct grounded in a sociocultural context that influences decision-making. 28 Furthermore, most research on the reasons and challenges related to blood donation during the COVID-19 pandemic is quantitative in nature, with relevant qualitative research being scarce. The few qualitative studies are mainly concerning the motivations and deterrents of blood donation in non-COVID times in Uganda, 29 Brazil, 30 Malaysia 31 and Britain. 32 Altruism, helping others and having free check-ups are noted as the key motivations, 17,[29][30][31][32] whereas fear of needles and blood, lack of awareness and access to blood donation facilities are noted as the key barriers. 17,29 Guglielmetti Mugion et al. 17 further identify service quality and information and communication are key determinants for people to donate blood. Little is known about blood donation behaviours in Chinese communities during the COVID-19 pandemic.
Understanding how individual motivations to give blood are altered during a pandemic can assist health authorities in developing a socially and culturally responsive blood donation promotion strategy during future epidemics. Our research, thus, aimed to fill the aforementioned literature gap through an in-depth investigation of the personal, social and institutional reasons for blood donors to donate and not to donate blood during the COVID-19 pandemic.

| Study design
A qualitative approach involving 40 in-depth, individual semistructured interviews was adopted to obtain data. Interviews were openended to enable free-flowing conversations between researchers and interviewees. 33 The inductive nature of in-depth interviews is effective for learning about people's beliefs, perceived meanings and interpretations. 34

| Data collection
Purposive sampling 33 was conducted to recruit participants meeting the following criteria: (1) Hong Kong residents who lived and received education in Hong Kong, (2) aged 18-66 years, (3) had previously donated blood and intended to donate blood in the future and (4) did not donate blood during the COVID-19 pandemic since January 2020. These selection criteria ensured the investigation of barriers to donating blood among blood donors during the COVID-19 pandemic, and that the participants had extensive social exposure to the Hong Kong setting. The age range was set as 18-66 years because people of this age are eligible to donate blood in Hong Kong in accordance with the regulations of the Hong Kong Red Cross Blood Transfusion Service.
An interview question guide (see Supporting Information: Appendix 1) was used to maintain the focus of the interview while allowing an in-depth discussion of topics. 34 The topics of concern in the interview question guide, which were referenced from past literature about blood donation in epidemic times, 1,4,[7][8][9][11][12][13]19,35 include interviewee perceptions, considering factors, motivations and barriers to donating blood during the COVID-19 pandemic.
A total of 40 participants were recruited between December 2020 and March 2021. These participants were recruited in three phases. In the first phase, three individuals were selected from a survey pool at a local university. The survey pool was from an earlier cross-sectional survey study on 542 undergraduate students about their knowledge and motivations in blood donation at a local university, 36  | 3193 the later interview study; 3 respondents were successfully contacted and agreed to be interviewed. Then in the second phase, recruitment posters listing the sampling criteria were placed at a local university's public facilities, such as the notice boards in the public areas of podium, activity areas and in canteens, with seven participants recruited. However, the use of these two strategies resulted in a sample of only university students and staff. Therefore, in the third phase, 30 participants with different demographic and socioeconomic backgrounds were recruited from the community, such as from social service centres, residents' associations and leisure and religious groups in different districts, in an attempt to minimize the selection bias.
To ensure interview consistency, each participant was individually interviewed by the same interviewer, who also served as a research associate of the study. The interviewer has bachelor's and master's degrees in sociology and qualitative research background.
The interviewer received rigorous interview training from the first author before conducting the interviews. The first and second authors supervised and assisted the interviewer throughout the data collection process. The interviewer did not know the participants personally before to ensure the interviews were conducted with minimal bias. All the interviews were conducted in Cantonese, which is the native tongue of the interviewer and participants, to facilitate interactions. Probing questions were also asked to follow up on the participants' responses.

| Ethical approval
Ethical approval was obtained from the Human Subjects Ethics Subcommittee at Hong Kong Polytechnic University (reference number: HSEARS20171013002) before data collection. The study procedures were explained to each participant before their interview.
The provided information sheets were prepared in traditional Cantonese (the participants' native language). Participants were assured that participation was voluntary. The participants in the online video interviews provided recorded verbal informed consent before the interviews, and the in-person interviewees provided written informed consent. To protect participant privacy, no identifying information was collected in the audio or coded data.
All the data were stored in password-protected files, and interview transcripts were coded with anonymous identifiers to protect participant privacy. After the interviews had been transcribed, the audio recordings were destroyed.

| Data analysis
Thematic content analysis was conducted to analyse the collected data. Interviews were transcribed verbatim. All interview transcripts were read and reread to achieve a general understanding and familiarity with the participants' experiences. Inductive coding was used to create coding schemes that allowed for the discovery of behaviour and thinking patterns. 33,34 A coding table with interview quotations was created to identify themes, categories and codes.
After cleaning the interview transcript data, the transcriptions were divided into meaning units through abstraction and continual comparison. Codes were identified, and they were recorded in a coding table with supporting interview quotes. Similar codes were then compressed into categories and finally themes. New thematic codes that arose from the data as well as recurrent codes and themes were added to the coding table. Informant codes were added to the coding table to allow tabulation and the discovery of patterns. During the interview and coding process, memos were used to capture ideas and commentary. A codebook was used to record specific data. 33 To guarantee the consistency and accuracy of the acquired data, the analytical procedures, coding and findings were documented in the codebook. To ensure that participant opinions were appropriately conveyed, direct interview excerpts were used, and the data analysis was grounded in these excerpts.
The first, second and third authors have extensive experience in qualitative research, and they conducted the coding separately; the first author is an anthropologist, the second author is a professor in nursing and registered nurse whose expertise lies in narrative research and the third author has a training background in sociology at both bachelor and master level. The qualitative research background of the first three authors ensured they could handle coding independently. Meetings were held among the first three authors every 2 weeks to discuss the coded data, and a consensus on the findings was reached. For publication, selected interview quotes were translated from Cantonese to English. Back-translation was conducted to ensure that the meanings of the participant quotes were not distorted. Table 1 presents the demographic information of the participants.

| Participants
All the participants (N = 40) had completed at least one blood donation before the pandemic (before January 2020) and planned to do so again in the future. All the participants had not donated    The collective responsibility of COVID-19 could also arouse concerns from the participants' family members about their blood donation during the pandemic, serving as another demotivator for blood donation.

| Motivations to donate blood
Many of my family members are older, so I don't want to give them any more pressure. I don't just mean that they disagree with me going to medical places, but it's also me personally. I think that I should protect them and be responsible for their health by avoiding highrisk places. I don't want to expose myself to a known risk and make them get infected. (CD022)

Peer pressure
The negative response to blood donation during the pandemic from 12 participants' peer networks served as a strong demotivator for blood donation among them. Our data reveal that blood donation was sometimes used as a coping mechanism during the COVID-19 pandemic. Although many studies suggest that people are less prone to donate blood during the COVID-19 pandemic, 4,7-9,11,12,14 our findings suggest that a few participants might be more prone to donate blood during this time.
Echoed with a past study, 19 trust and confidence in blood donation centres were also important to enhance donation motivation. Thus, emphasizing the precautionary measures adopted at blood donation centres to enhance people's trust and confidence may facilitate blood donor retention during the pandemic.

| Limitations
The data were obtained from 40 current blood donors who did not donate blood during the COVID-19 pandemic in Hong Kong.
Additional research on those who donate during the pandemic may provide more information about donation motivations. The high percentage of the participants possessed at least a university degree also makes this study include mostly the ideas of those with a tertiary education level. Future research should consider interviewing those with a lower education level.

| CONCLUSION
This study provides a macro understanding of blood donation