Barriers and motivators of Ghanaian and African‐Surinamese migrants to donate blood

Abstract African migrants are underrepresented as blood donors in many Western countries, which can lead to shortages of specific blood types for transfusion. More insight in the reasons for this underrepresentation is required to improve blood donor recruitment and retention strategies. The aim of this qualitative study was to explore barriers and motivators for donating blood among migrants of African background. The research population consisted of first and second generation African‐Surinamese (n = 20) and Ghanaian (n = 16) migrants living in the Netherlands. In semi‐structured personal interviews performed in 2016 and 2017, their experiences and opinions regarding blood donation, barriers, and motivators to (not) become a blood donor and their suggestions to improve recruitment were explored. Data collection was continued until data saturation was achieved. The interviews revealed that although all participants knew about blood donation in general, only four had previously heard of the Dutch national blood bank organisation. Participants expected that if blood was needed, the blood bank would directly approach them, as in their country of origin. Other main blood donation barriers were fear (e.g., of needles, losing too much blood) and issues related to health and non‐eligibility to donate. Main motivators were mainly of altruistic nature (e.g., saving a life) and an increased awareness of the need via personal recruitment appeals. It is concluded that expectations regarding donor recruitment—derived from the country of origin—and unawareness of the need for blood can act as important barriers in blood donation among African migrants. Contrary to studies in the United States and Australia, perceived discrimination and social exclusion did not seem to be a donation deterrent among migrants in the Netherlands. Creating awareness of the need of blood by actively approaching, and informing migrants about the donation procedure in the host country, should be considered by blood banks.


| INTRODUC TI ON
The recruitment and retention of blood donors from various ethnic backgrounds is increasingly important for an adequate supply of blood.
However, in many Western countries, migrant minorities are underrepresented in the blood donor pool (van Dongen, Mews, de Kort, & Wagenmans, 2016). This underrepresentation presents a problem, since ethnic diversity in Western society is growing and some minority groups differ in extended blood typing compared to a country's majority population (Reid, Lomas-Francis, & Olsson, 2002). One important group with unique blood phenotypes, as compared to people of Western-European origin, are people from Sub-Saharan African (SSA) origin (Howes et al., 2011). When the blood types of donor and patient cannot be fully matched, the patient may become alloimmunised and future incompatible transfusions may lead to fever, hypotension, and even death. To prevent alloimmunisation and its serious complications, SSA patients are often in need of precisely matched blood, also with regard to these extended blood types (Yazdanbakhsh, Ware, & Noizat-Pirenne, 2012). Although migrant SSAs are underrepresented as donors, SSAs are not underrepresented as chronic transfusion patients (Miller et al., 2013). To ensure a sufficiently diverse and stable blood supply, more SSAs need to be recruited and retained as blood donors.
Previous studies on blood donation barriers and motivators among African minorities and migrant groups, demonstrated that discrimination, social exclusion, and distrust are often perceived and experienced as barriers for donating blood, as they felt their blood would not be wanted by the white majority population and be wasted (Polonsky, Brijnath, & Renzaho, 2011;Tran, Charbonneau, & Valderrama-Benitez, 2013). Also, preferences for donating within the own community or family, and symbolism surrounding blood are indicated in various studies Grassineau et al., 2007). But a systematic review on African donation barriers and facilitators also demonstrated that general factors play an important role, such as fear, convenience, and eligibility Klinkenberg et al., 2018).
Most studies are focused on African-Americans in the United States, with a few performed on African communities in Canada and Australia Polonsky, Renzaho, & Brijnath, 2011;Schreiber et al., 2006;Shaz, Demmons, Hillyer, Jones, & Hillyer, 2009). Perspectives from European countries are lacking. While the challenges and needs of recruiting more African minorities and migrants are similar worldwide, the socioeconomic contexts are not (Kivisto, 2002). Most African minorities in the United States are living there for many generations, while in Europe, most African minorities migrated from Africa to another country, or are born from migrants.
These different upbringings and contact with the country of origin, may bear on different perceptions and experiences with blood donation compared with the native majority group or even minority groups who are settled in a country for multiple generations. Therefore, more insights in specific African migrant communities in Europe are needed to improve blood donor recruitment strategies.

| The Dutch context
The Dutch national blood collection agency (BCA), named Sanquin, depends on voluntary, non-remunerated blood donors who can donate up to three to five times each year and is the only BCA responsible for the Dutch blood supply (Sanquin, 2016). As in many other countries, migrant recruitment and blood-matching is becoming an important subject for research and practice because of growing migration and thus the growing demand of specific blood products (van Dongen et al., 2016). In 2017, more than 240 thousand SSAs live in the Netherlands, representing about 1.4% of the total Dutch population (Statistics Netherlands, 2016). A relatively large part of the SSAs originates from Ghana (23,000; 11.2%). However, the largest group of African descendants (not from the African mainland) originates from Surinam. This group is often referred to as African-Surinamese or Creoles, and about 39,000 of this Surinamese sub-group were estimated to live in the Netherlands in 2008, for which unfortunately no new statistics are known (Oudhoef, Harmsen, Loozen, & Choenn, 2011). Although the number of SSA descendants-both from former colonies and the African mainland-is relatively small compared to the Turkish (397,000) and Moroccan (386,000) communities, the SSA community is expected to grow and differ more on extended blood typing (Carling & Hernández-Carretero, 2011;Connell, Zurn, Stilwell, Awases, & Braichet, 2007;Statistics Netherlands, 2015). The majority of both groups live in the capital of the Netherlands: Amsterdam.
To explore the blood donation barriers and motivators of these two large African groups, and find more efficient ways to recruit and retain What is known about this topic • Personal recruitment and awareness raising are needed to reach and inform African migrants.
• Unlike earlier studies, discrimination and social exclusion were not reported as major barriers in the Dutch context. them as blood donors, the PRECEDE-PROCEED model was selected to guide our assessment (Green & Kreuter, 1991 changes. This approach is part of a systematic intervention development using the Intervention Mapping protocol (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011), in which the results from multiple studies form the basis of new SSA blood donor recruitment and retention strategies. This particular study aimed to identify barriers and motivators experienced by African-Surinamese and Ghanaian migrants to become a blood donor in the Netherlands, with the aid of this framework.

| Participants and recruitment
Individuals for semi-structured qualitative interviews with an African-Surinamese background were recruited from participants in the Healthy Life in an Urban Setting (HELIUS) study in Amsterdam (Snijder et al., 2017;Stronks et al., 2013). The HELIUS study is a prospective cohort study among a multi-ethnic population, with a main focus on cardiovascular diseases, infectious diseases, and mental health. The African-Surinamese participants of the HELIUS study were personally asked to participate in the interview after the main HELIUS examination. Ghanaian participants were recruited via a certified care provider, who focused mainly on the care of African communities.
People were personally invited to participate in an interview if at least one parent was born in Ghana or Surinam, or if the participant was born in that country himself/herself and was aged 18 years or older. Blood donor status and eligibility to donate were not inclusion criteria for this interview study. Participants had to be fairly fluent in Dutch or English.
A total of 36 interviews were completed: 20 with African-Surinamese and 16 with Ghanaian participants ( Table 1). The interviews lasted on average 30 min. In both groups, more women than men participated. Three persons were second-generation migrants.
None of the participants was currently a blood donor, whereas about 25% of the participants had donated blood in the past. From those who donated in the past, three participants reported to have donated in the Netherlands, while six had only donated in their country of birth.

| Data analysis
All interviews were recorded and transcribed completely. The transcripts were coded and analysed in MAXQDA software for qualitative data analysis (version 12, VERBI, GmbH, Germany). Thematic analysis was done by authors MF and EK. Based on the PRECEDE-PROCEED model, a coding framework was developed in which the barriers/motivators were divided into predisposing, reinforcing, and enabling factors ( Figure 1) (Green & Kreuter, 1991

| Altruism
All participants mentioned that an important reason to donate blood was based on altruism, that is unselfish devotion to others' well-being. Participants argued that you should not expect something in return for doing a good deed such as donating blood and some participants seemed to compare donating blood with voluntary work or giving a gift to someone: "Voluntary. You give to give.
From your hearts." (Female, 46 years, Ghanaian background). Also, giving blood was often seen as a moral responsibility and as compassion towards the patient: 'The child needs blood to survive and if somebody donates to this child, he might become the next president or a pilot.
[…] If that person will not get blood, he will die and everything is gone. So blood donation is good […] Just from the hearts and own will.' (Male, 53 years old, Ghanaian background).
Although it was not as often reported as purely altruistic motivators, seven participants mentioned immaterially benefiting from donating blood would motivate them (19%). One example is experiencing positive emotional feelings, as a participant explained who had donated previously: "It's just a nice feeling you get. You always get something back if you do something good, if you help others.

| Incentives
Incentives, such as money and gifts, were generally not consid-

| Anonymity, family donation preferences, and peer influence
In the Netherlands, donors do not know the recipient and vice versa. Two of the four Surinamese past donors, and one of the five Ghanaian past donors, mentioned they had given blood specifically for a family member. However, when asked if they were interested in who received their donated blood, most participants reacted indifferent and thought that this should be irrelevant: "If someone needs the blood, he just needs it, no matter who it gives.
And the other way around too; if I need blood it won't matter to me from who it is, as long it is good and healthy blood." (Male, 28 years, Surinamese background).
Four participants mentioned preferences regarding the recipient of their blood donation (11%); this was mainly observed among Surinamese woman with children. The preference often goes together with some kind of fear, for example for needles, or your blood going into someone else's body (i.e., seen as giving a part of yourself to a stranger): "I need to help my child. It may be unfair because it's my own child, but my blood is in there, so it doesn't matter.
Although for some participants family is imperative as the re- However there is evidence that when close family members donate blood, the participant is more inclined to give blood: "Yes, their [my family members"] experiences were very good. In Surinam they did it and here they also do it. That's why I also wanted to do it.' (Female, 60+ years, Surinamese background).

| Health
Some participants mentioned that they did not donate blood due to their current health status. One Ghanaian man who had donated in the past said that he was not able to donate blood anymore: "I would donate it! But, this one [points to right arm] stroke. From my hand and leg" (62 years). Also, one Ghanaian woman said that she wanted to become a donor, but that it was not possible for her: "I gave one time and then a doctor told me my blood is not good because of my hepatitis B." (46 years). Five Surinamese respondents mentioned a low haemoglobin level or iron deficiency as a barrier (25%). Based on our observations and the participants' reports, it is estimated that at least five of the Ghanaian participants (31%) and four of the Surinamese participants (20%) would be definitely excluded from blood donation with the current health eligibility criteria of the Dutch BCA, for instance, due to earlier transfusions or reported infectious diseases.

| Practicalities
In general, participants felt they should be asked to donate at a convenient moment; otherwise they will not do it: "I think the only thing is the circumstance -if they ask if I can come on this or that day and I'm not able to at that moment." (Male, 60+ years, Surinamese background). It was also noted by most participants that the donation site should be in their own neighbourhood: '… if it was around the corner from my house. So, if it was easy, and they'd say: "come along to donate blood", then I would do it.' (Male, 28 years, Surinamese background). However, time constraints and accessibility of the donation site did not seem to be a major barrier for the participants if the need for blood was high.

| Recruitment strategies
The participants were asked how the recruitment of the BCA might be improved, and what kind of strategy would motivate them. One desired strategy was to make people more aware and inform them about the BCA and blood donation: 'They could go just into the streets, to a market. But also advertise in the newspapers and do commercials on TV and radio […]

| D ISCUSS I ON
In the present study, interviews were conducted with African-Surinamese and Ghanaian individuals to determine barriers and motivators for blood donation in the Netherlands. The main predisposing barrier was a lack of awareness. Participants generally had more knowledge about blood donation in their country of birth.
But also fears associated with donating blood were regularly mentioned, such as fears related to needles, fainting, or losing too much blood. Regarding the reinforcing factors, altruism appeared to be the main driving force to donate blood. However, some participants mentioned family donation preferences or incentives in the form of foods or snacks as reinforcing motivators. Of the enabling factors, participants preferred a personal approach highlighting the need for blood, which was reported as a more usual practice in the country of origin. Finally, health problems and non-eligibility were reported as major deterrents for blood donation, which is often found to be a barrier among people of African origin in other countries as well (Cable et al., 2011;Grassineau et al., 2007).
Some of our findings contrast with the results of earlier studies on African minorities. Personal discrimination and social exclusion were previously found to be major factors for not donating blood, for instance, because people felt their blood is not wanted by the majority population (Polonsky, Brijnath, et al., 2011;Tran et al., 2013). In our study, these factors were not reported and not perceived as a barrier to donate blood. This result might be attributed to the high level of social tolerance in the Netherlands (Weldon, 2006).
However, this might also be a non-finding since both interviewers were of Dutch ethnic background, which may have acted as a barrier to freely speak about experiences related to discrimination or social exclusion (Adida, Ferree, Posner, & Robinson, 2016). Mistrust of the BCAs or the health system was also important barriers in other studies (Frye et al., 2014;Polonsky, Renzaho, et al., 2011 A major finding of this study is that practices from the country of origin, where more manifest blood donation appeals are made and people are directly asked to donate for a family member, influenced the expectations of blood donation in the Netherlands. People believed that the blood supply is sufficient, as they were never directly or indirectly asked to donate blood. The Dutch BCA rarely does appeal on family-members of a transfusion patient and it is more common practice that potential-donors register at the BCA individually on own initiative (World Health Organisation, 2017), which contrasts with the past donation experiences reported in the interviews, although Surinam now also depends entirely on voluntary, non-remunerated donors. In Ghana, less than half donates voluntary and non-remunerated. From the interviews, it can be concluded that these differences were not perceived as donation deterrents, but the participants were generally not aware of these country-specific procedural differences. The expectations derived from the country of origin, should be taken into account in future research.
Since most participants were never reached by the Dutch BCA and had not thought about donating blood, it was sometimes difficult for them to consider other barriers. Yet, the overall opinion on blood donation was positive. Therefore, it is warranted to improve the visibility of the BCA. We do recognise, however, that building awareness alone is not enough to recruit and retain more donors, as multiple intervention studies have pointed out (Francis, Polonsky, Jones, & Renzaho, 2017;Frye et al., 2014). Therefore, other interventions based on the migrants' expectations and desires should be examined, such as providing more clarity on what happens with the blood after donation and providing food packages. Still, the current eligibility criteria can act as a barrier once SSA minorities are recruited, as many participants reported health-related issues that exclude them from blood donation. Besides, SSAs often travel to their country of birth and have relatively low haemoglobin levels (Cable et al., 2011;Grassineau et al., 2007). Communicating with this group about the necessity of the eligibility criteria to protect both the donor and patient, might increase successful donations as some deferral criteria are linked to lifestyle behaviour. Creating awareness of the need of blood by actively approaching migrants of African descent, and appropriately informing them about the donation procedures should be considered by BCAs aiming for a more diverse donor pool. A quantitative study will follow the current study, in which the identified barriers and motivators will be assessed among a large sample.

ACK N OWLED G EM ENTS
The authors would like to thank all our interview participants for sharing their opinions, experiences and ideas with us.