Lack of standardization of blood donor recruitment processes: A two-center mixed-methods audit study in Ghana

Abstract

Objective:

Sub-Saharan African countries perennially suffer acute donor blood shortfalls. Clinical audit is a quality improvement strategy that enables the identification of actionable points to improve healthcare delivery. This study audited the blood donor recruitment processes at two Ghanaian secondary healthcare facilities to identify areas that can be leveraged to improve donor blood stocks.

Methods:

This was a sequential, exploratory mixed-methods study. First, 30 real-time observations of prospective blood donor-laboratorian interactions were undertaken using checklists. Subsequently, 2 sets of semi-structured questionnaires were used to collect data on pre-donation screening, blood donor privacy, and postblood donation care from the perspectives of 135 blood donors and 134 laboratory staff.

Results:

The observational data collection found a general inter- and intrapractitioner variation in blood donor recruitment procedures. Overwhelmingly, prospective donors were males (91.1%), or 20–39 years old (80.7%). Also, only 5.9% of prospective donors were voluntary nonremunerated, whereas 34.8% were deferred. Overwhelmingly, laboratory staff and prospective donors indicated that neither donor information leaflet (97.0% versus 98.5%, respectively), nor medication deferral list (93.3% versus 97.8%, respectively) was employed during the blood donor screening process. Also, whereas 88.2% of successful donors indicated being unaware of any focal person to contact in the event of adverse postdonation symptoms, laboratorians indicated that there was no focal person for handling issues related to successful (94.8%) or deferred (90.0%) blood donors. Furthermore, 42.3% of laboratorians indicated that prospective donors with permanent deferral results are fully informed, compared to 58.2% who indicated uneasiness when disclosing reactive screening results.

Conclusions:

The adoption of standard operating procedures may help prevent interfacility and interpractitioner variability in blood donor recruitment practices. Interventional implementation research may help to improve pre- and postdonation services offered to both successful and deferred donors in the study settings.

Keywords

blood donor recruitment blood donation audit of blood donation processes mixed-methods blood donor deferral

Significance for public health

The use of the universal history questionnaire in the blood donation screening processes protects the prospective recipients from at-risk individuals who might be harboring transfusion-transmitted infections (TTIs) during the window period. This article highlights a lack of implementation of standard operating procedures at two secondary healthcare blood collection centers, which might increase the risk of TTIs for blood product recipients at these centers. Additionally, it highlights a need to build the capacity of blood collection center staff to adequately handle blood donor deferrals and postblood donation care.

Introduction

Although blood transfusion is a critical component of the healthcare delivery system, sub-Saharan African (SSA) countries often struggle to meet their annual blood donation requirements. The high anemia burden leads to a concomitant increased transfusion requirement that can only be met with a commensurate increased blood donation. It is estimated that 10 blood donations per 1000 population (1% donation rate) is necessary to achieve donor blood sufficiency in any population.^1,2 Compared to industrialized countries that are able to achieve 5% blood donation rate per population, developing countries achieves only 0.3% blood donation rate resulting in a perennial shortfall in blood requirements. Consequently, this perennial blood shortfall in SSA has been found to be associated with neonatal and maternal mortalities.^3,4 With an estimated majority youthful population in SSA, these countries should theoretically be able to mobilize adequate quantities of blood products. Thus, there is a prevailing paradox in SSA in which there is a perennial blood shortfall in spite of a majority youthful population that meets the age limit requirement for blood donation. This warrants studies that explore all stakeholders for potential actionable points to improve the blood donation rate per the respective population.

Healthcare professionals employ clinical audit as a quality improvement strategy to identify actionable points that, when addressed, can improve the efficiency of healthcare delivery and patient outcomes. When meticulously applied in the context of blood donor recruitment, audit of the blood donor recruitment process could help unearth areas that have a bearing on blood donor satisfaction, donor recruitment, and retention as part of the strategies to ensure a stable blood supply.⁵ Clinical audit could thus be an essential component of evidence-based laboratory practice⁶ to sustain best laboratory practices. In this mixed-methods study, we audited the blood donor recruitment processes at two blood donor recruitment centers to explore the existence and adherence to standard protocols such as the universal donor history questionnaire (UDHQ), blood donor information sheet, medication deferral list, and prospective donor deferral protocols. Taken in context, our study audited the preanalytical (predonation donor screening), analytical (donor bleeding), and postanalytical (postblood donation care, deferred donor management) phases of the blood donor recruitment processes.⁶ Using researcher observations and quantitative data collections from perspectives of prospective donors as well as laboratory professionals at the blood collection centers, we aimed to interrogate the actual lived experiences of blood donors and blood collection staff to triangulate data sources to improve quality/rigor of the eventual data.

Methods

Study design

The study was as a sequential exploratory study that employed mixed-methods approaches to collect data from participants. Specifically, observations of the blood donor recruitment processes were undertaken at the two facilities to collect real-time data on the blood donor-practitioner interactions. Subsequently, two sets of semistructured questionnaires were employed to collect data from prospective blood donors and laboratory staff. The study period was between August 2022 and February 2023. The reporting of this study conforms to Strengthening the Reporting of Observational Studies in Epidemiology guidelines for reporting of observational studies.⁷ The data collection strategy is illustrated in Figure 1.

Figure 1.

A diagram illustrating the sequential exploratory data collection strategy for the study. The stepwise nature of the diagram illustrates the sequential data collection strategy. Note that all activities in stage 1 were completed before commencing stage 2; stage 3 activities also commenced only after completing stage 2.

Audit cycle

A laboratory-based clinical audit cycle has five stages,⁸ namely preparation phase (where a relevant topic is selected), selecting benchmarks (for performance comparison), measuring performance (through data collection), analyzing and presenting findings, and implementing changes and re-auditing. Our present study fully covered the first three phases: phase 1 (auditing the blood donor recruitment process), phase 2 (benchmarks: using the UDHQ), and phase 3 (measuring performance through observation and questionnaire data collection). Additionally, phase 4 is partially covered by this report (and also partially by the interactions we have had with the two hospitals where the study was undertaken). Implementation of the findings and subsequent reauditing will be covered in future studies.

Blood donor screening protocol

Within the existing blood donation protocols of the Ghana Health Services, all in-hospital blood donors undergo an initial hemoglobin check, physical examination (weight, blood pressure, temperature, pulse), and transfusion-transmitted infections (TTIs) testing using rapid test kits. Only those that pass this initial screening are bled. Such blood units are then further screened using ELISA. However, for mobile blood mobilization drives, only hemoglobin levels are estimated (together with physical examinations) at the mobile blood collection site. Those that pass these preliminary screenings are bled at the mobile blood collection site; the blood is then taken to the blood bank and then screened for TTIs.

Study area

The study was carried out at two blood collection centers in Ghana; the Bibiani Government Hospital laboratory, Bibiani, Ghana in the Bibiani Anhwiaso Bekwai Municipal District (Western North Region), and the Nagel Memorial Adventist Hospital in the Sekondi-Takoradi metropolis (Western region). The Bibiani Anhwiaso Bekwai Municipal District is bounded on the North by the Atwima Mponua District in the Ashanti Region, South by the Wassa Amenfi in the Western Region, West by the Sefwi Wiawso District in the Western Region and East by the Denkyira North and Amansie East in the in the Central Region and Ashanti region, respectively. Conversely, the Sekondi-Takoradi metropolis is bordered by Ahanta West District, Shama District, the Atlantic Ocean, and Mpohor-Wassa East District in the west, east, south, and north, respectively. Each of the hospitals operates a 24 h in-patient and out-patient services and serve as referral centers for the healthcare facilities within their respective districts.

Study population

All consecutive prospective donors who visited the blood collection centers during the period of the study were approached for recruitment to the study; however, only those who gave informed written consent were enrolled in the study. Additionally, all medical laboratory professionals at each of the blood collection center were also invited to participate in the study. However, in order to get an appreciable number of laboratorians who work in blood collection centers, other laboratory staff within each of the districts where the study was undertaken were also invited to participate in the questionnaire data collection.

Inclusion/exclusion criteria

All consecutive prospective blood donors (aged ⩾17 years) who visited the facilities during the study period and gave informed written consent were recruited. However, all prospective donors who were deferred for not meeting ⩾1 of the blood donor eligibility criteria were excluded. Also, only laboratory staff who gave written informed consent were recruited for the study.

Sample size

For this study, a total of 30 observations of prospective blood donor recruitment procedures were made: 15 observations at the Bibiani Government hospital blood collection center, and 15 observations at the Nagel Memorial hospital blood collection center. For the questionnaire data collection, a total of 135 prospective blood donors and 134 laboratory staff were consecutively recruited for the study. Given the low blood donation rate in the study area, no power calculations were made in estimating the sample size for prospective blood donors recruited for this study.

Sampling technique

A purposive nonprobability sampling technique was employed to recruit participants through a convenience sampling technique. All prospective blood donors were invited to volunteer for the study; those who consented were enrolled to the study. Also, consecutive laboratorians working in blood collection centers within the respective districts who consented were also recruited for the study.

Data collection and management

Data collection was intentionally sequential (Figure 1): observations were made at each of the blood collection centers first. After completing the 30 observations, questionnaire data collection from the perspective of prospective blood donors were undertaken. Only after completing the prospective blood donor questionnaire data collection did we commence questionnaire data collection from laboratorians.

Observation stage

The researchers observed the whole blood donation process from donor screening through to post-blood donation care at each facility and recorded the observations verbatim. The researchers used a checklist to audit the blood donor recruitment process (Supplemental File S1). The observation data collection at each facility was continued until further observations did not reveal any new information. At that stage, the data collection was considered to have reached saturation.

Questionnaire data collection

Two sets of semi-structured questionnaires (enclosed as Supplemental File S2) were administered to solicit information: one to prospective blood donors and the other to laboratory staff. The prospective blood donor questionnaire had four sections: part 1 sought information on participants’ sociodemographic characteristics (age, sex, marital status, educational status and type of donor). Part 2 sought information on predonation screening and knowledge about deferral status. Part 3 sought information on blood donation privacy and predonation screening results/information disclosure. Part 4 sought information on the depth of information on postblood donation care given to blood donors. The laboratory staff questionnaire also had four sections: Part 1 (Background information), part 2 (Pre-donation screening information disclosures), part 3 (Postdonation care), and part 4 (Information about perceived barriers to practitioner-blood donor communication). In parts 3, 4, and 5 of both prospective blood donor and laboratory staff questionnaires, participants judged their agreement with specific statements on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The prospective donor questionnaire and the laboratorian questionnaire were initially pilot-tested on 20 prospective donors and 10 laboratorians, respectively. This pilot testing provided the needed feedback that allowed the researchers to modify the constructs before the commencement of data collection.

Data analysis

Data was entered into Microsoft Excel 2016 for processing and was analyzed using SPSS version 22.0 (IBM Inco., New York, USA). The data was de-identified before data analysis to preserve participants’ anonymity. For the observation data, a summary has been provided in the results section. The quantitative questionnaire data were presented as frequencies and percentages. In the quantitative data analyses presented in Tables 2 and 4, the strongly agree and agree categories were merged as agree, whereas strongly disagree and disagree were also merged as “disagree” to ultimately provide three scales, that is, disagree, uncertain, and agree. All statistical testing was determined using a chi-square test under the two-tailed assumptions; the significance level was set at 0.05.

Results

Observation stage

Blood donor recruitment and bleeding rooms

Generally, in each of the laboratories, the donor room assigned for donor recruitment was a dedicated room with comfortable seats, but the rooms had challenges with ventilation. The bleeding room had sufficient lightning as well as comfortable beds. The rooms were also fitted with curtains that demarcated an area that served as a predonation screening area, and thus separating it from the main bleeding area. This provided some degree of privacy during the blood donor screening process. Procedures also monitored included how potential clients were identified, information given before taking donor blood samples for screening, information given to clients after the results were ready and whether laboratory test results were entered into the laboratory record book.

Client identification

Prospective blood donation clients were identified through various means. Most of the donors walked-in to the blood collection unit and identified as paid donors (and were willing to donate blood if given some incentives especially cash), or came to donate blood for a relation (family/replacement donors). A few of the clients walked in as voluntary donors without expecting any incentive in return. Voluntary donors were given donor cards, which were explained by the laboratory staff to mean that their voluntary gesture qualified them to receive free blood units if they ever needed a blood transfusion in the future.

Interaction between prospective donors and laboratory staff before sampling

Neither of the two blood collection centers used structured blood donor recruitment protocols, blood donor information leaflets, medication deferral leaflets, or any printed version of the UDHQs. Thus, although the laboratory staff explained the blood donation procedure to the prospective donors, the predonation screening procedures were variable between practitioners and even with the same practitioner. Generally, the prospective donors were informed on the need to take blood samples to perform screening tests to check for TTIs. Additionally, in majority of the cases, the prospective donor was asked if they knew their blood group and the last time they donated blood. Specifically, with respect to the family/replacement donors, the laboratory staff usually gave the prospective donor some information: “You can only donate blood if you have the same blood group as the relative, pass the screening process for TTIs and have enough haemoglobin level.” Generally, time for sample taking by laboratory staff ranged between 15 s to 3 min with an average of 60 s.

Post TTI screening information disclosure

The major explanations offered to prospective blood donors who were disqualified were recent blood donation, medical history, lifestyle habits, and recent completion of menses (for female donors). In such instances, the donors were deferred immediately without performing any further tests. Other donors were disqualified based on low hemoglobin level and positive TTI test results. In instances where the clients were disqualified, some were just informed they had failed the blood donation process without being given any particular reason. In such instances, where reasons were given for the disqualification of the prospective donor, they were either informed of the specific TTI to which they tested positive, or it was generalized that they had tested positive to a TTI. In all cases where specific reasons were provided to the disqualified donor, the information matched the testing results. Only occasionally were disqualified prospective donors given thorough explanations about a reactive screening test; this usually occurred as a consequence of the curiosity of the deferred prospective donor. It should be noted that regarding family/replacement donors, some were disqualified solely because their blood group was not an exact match of their relative in need of blood.

However, prospective blood donors who qualified were informed they had tested negative for all the test which were done and as such can donate. Subsequently, they were instructed to go and eat and return for the bleeding process; only in few instances (usually paid donors) were the prospective donor instructed to follow the laboratory staff to the bleeding room without being informed to go and eat.

Documentation of laboratory testing results

In most instances, results of laboratory testing after the screening process were not immediately entered into the laboratory record book. In a few instances however, the records were appropriately entered into the records book. This was mostly done after the whole blood donor recruitment and/or blood collection process had been completed and the donor had left the facility.

Quantitative questionnaire data collection

Sociodemographic characteristics of participants

The sociodemographic demographic variables of study participants are presented in Table 1. Both prospective donors (91.1%) and laboratory professionals (71.6%) were predominantly males. Also, whereas the laboratory professionals were mostly in their 30s (79.1% in the 30–39 years age group), nearly 1-in-2 (49.6%) of the prospective donors were in their twenties. Whereas the Medical laboratory scientist was the predominant cadre among the laboratory professionals, secondary educational attainment constituted a slight majority among the prospective donors. Furthermore, nearly a third of both prospective donors (63.0%) and laboratory professionals (62.7%) were recruited at the Bibiani government hospital. In addition, among the prospective donors, whereas nearly 6-in-10 were family replacement donors, less than 1-in-10 were voluntary donors. Whereas none of the voluntary donors were however women, overwhelming 91.7% of the prospective female blood donors were family replacement donors.

Table 1.

Sociodemographic details of study participants.

Blood donors		Lab staff
Variable	n (%)	Variable	n (%)
Age (years)		Age (years)
17–19	15 (11.1)	15–19	–
20–29	67 (49.6)	20–29	25 (18.7)
30–39	42 (31.1)	30–39	106 (79.1)
40–49	10 (7.4)	40–49	3 (2.2)
50–59	1 (0.7)	50–59	–
Sex		Sex
Female	12 (8.9)	Female	38 (28.4)
Male	123 (91.1)	Male	96 (71.6)
Education		Grade
Nonformal	4 (3.0)	MLS	78 (58.2)
Basic	21 (15.6)	Intern	6 (4.5)
Secondary	42 (31.1)	Principal/Senior MLS	8 (6.0)
Vocational	8 (5.9)	Senior technician	24 (17.9)
Tertiary	15 (11.1)	Technical officer	18 (13.4)
Place/Hospital		Place/Hospital
Bibiani GH	85 (63.0)	Bibiani GH	84 (62.7)
Nagel MH	50 (37.0)	Nagel MH	50 (37.3)
Blood donation type
Voluntary unpaid	8 (5.9)
Family/replacement	80 (59.3)
Paid	47 (34.8)

GH: Government hospital; MH: Memorial hospital; MLS: Medical laboratory scientist.

Participants knowledge regarding predonation screening processes

The perspectives of both prospective blood donors and laboratory professionals regarding the pre-donation screening procedures were explored (Table 2). Overwhelming majority of the prospective donors (86.7%) indicated that all questions relating to blood donations were answered by the blood donor recruitment staff; this was corroborated by the laboratory staff as 99.3% indicated making effort to answer prospective donor questions. Although nearly 7-in-10 prospective donors affirmed that blood donation processes were explained, this was disproportionately represented in participants from Bibiani government hospital (83.1% versus 44.0% from Nagel Memorial hospital; p < 0.001). Also, although nearly 7-in-10 of laboratory professionals affirmed that all the blood donation procedures were explained to prospective donors, this was disproportionately over-represented by participants from the Bibiani government hospital (98.8% versus 20.0% of participants from Nagel memorial hospital; p < 0.001). Furthermore, a little over 7-in-10 of prospective blood donors indicated that they will encourage others to donate and will re-donate blood if given the opportunity; however, these were overwhelmingly disproportionately over-represented by prospective donors from Bibiani government hospital. In relation to predonation information disclosures, although a little over 6-in-10 of laboratory professionals affirmed that they were satisfied with information disclosure to prospective donors, there was over-representation of laboratory professionals from Bibiani government hospital (95.2% versus 4.0% from Nagel Memorial hospital; p < 0.001). In agreement with this, whereas all the laboratory professionals from the Nagel Memorial hospital indicated that the deferral status were not adequately communicated to deferred donors, only 16.7% of laboratory professionals from Bibiani government hospital were not satisfied with the deferral disclosures. Overwhelmingly, both prospective blood donors (>97.0%) and laboratory professionals (>93.0%) indicated that neither medication deferral list nor blood donation information leaflets were available at each of the blood collection centers. Furthermore, although the prospective donors (85.9%) indicated that the blood collection staff were friendly, the laboratory professional overwhelmingly indicated that neither blood collection center has a policy on referring a deferred donor to clinicians for management.

Table 2.

Perspectives of prospective blood donors and laboratory professionals regarding predonation screening processes.

Prospective blood donors					Laboratory professionals
	Total (%)	Bibiani GH	Nagel MH	p-Value		Total (%)	Bibiani GH	Nagel MH	p-Value
There was enough privacy at the blood donation center to discuss my misunderstandings.				<0.001	We provide enough privacy at the blood donation center to allow our clients to discuss their fears.				<0.001
Disagree	50 (37.0)	1 (1.2)	49 (98.0)		Disagree	52 (38.8)	2 (2.4)	50 (100.0)
Uncertain	1 (0.7)	0 (0.0)	1 (2.0)		Uncertain	0 (0.0)	0 (0.0)	0 (0.0)
Agree	84 (62/2)	84 (98.8)	0 (0.0)		Agree	82 (61.2)	82 (97.6)	0 (0.0)
All my questions were adequately answered by the blood donor recruiting staff.				<0.001	We make efforts to adequately answer all questions asked by clients.				<0.001
Disagree	9 (6.7)	0 (0.0)	9 (18.0)		Disagree	0 (0.0)	0 (0.0)	0 (0.0)
Uncertain	9 (6.7)	3 (3.5)	6 (12.0)		Uncertain	1 (0.7)	0 (0.0)	1 (2.0)
Agree	117 (86.7)	82 (96.5)	35 (70.0)		Agree	133 (99.3)	84 (100.0)	49 (98.0)
All the blood donation procedures were explained to me.				<0.001	All the blood donation procedures are explained to clients.				<0.001
Disagree	23 (17.3)	8 (9.6)	15 (30.0)		Disagree	35 (26.1)	1 (1.2)	34 (68.0)
Uncertain	19 (14.3)	6 (7.2)	13 (26.0)		Uncertain	6 (4.5)	0 (0.0)	6 (12.0)
Agree	91 (68.4)	69 (83.1)	22 (44.0)		Agree	93 (69.4)	83 (98.8)	10 (20.0)
I will actively encourage other people to donate blood.				<0.001	I am satisfied with the predonation medical screening information disclosure to blood donors.				<0.001
Disagree	15 (11.2)	0 (0.0)	15 (30.0)		Disagree	46 (34.3)	4 (4.8)	42 (84.0)
Uncertain	18 (13.4)	1 (1.2)	17 (34.0)		Uncertain	6 (4.5)	0 (0.0)	6 (12.0)
Agree	97 (72.9)	83 (98.9)	18 (36.0)		Agree	82 (61.2)	80 (95.2)	2 (4.0)
I will donate blood again if given the opportunity.				<0.001	Deferral status is adequately explained to all those who are deferred to inform future blood donation choices.				<0.001
Disagree	13 (9.8)	1 (1.2)	12 (24.0)		Disagree	64 (47.8)	14 (16.7)	50 (100.0)
Uncertain	23 (17.3)	4 (4.8)	19 (38.0)		Uncertain	6 (4.5)	6 (7.1)	0 (0.0)
Agree	97 (72.9)	78 (94.0)	19 (38.0)		Agree	64 (47.8)	64 (76.2)	0 (0.0)
I was given blood donor information leaflet to read before the blood donation.				0.318	All prospective doors are given information leaflet to read before the blood donation.
Disagree	133 (98.5)	84 (98.8)	49 (98.0)		Disagree	130 (97.0)	80 (95.2)	50 (100.0)
Uncertain	1 (0.7)	0 (0.0)	1 (2.0)		Uncertain	3 (2.2)	3 (2.2)	0 (0.0)
Agree	1 (0.7)	1 (1.2)	0 (0.0)		Agree	1 (0.7)	1 (1.2)	0 (0.0)
I was given a medication deferral list to inform me of medications that will defer a prospective donor.				0.406	All prospective donors are given a medication deferral list to ensure that donors are not taking any such drug(s).				<0.001
Disagree	132 (97.8)	82 (96.5)	50 (100.0)		Disagree	125 (93.3)	75 (89.3)	50 (100.0)
Uncertain	2 (1.5)	1 (2.4)	0 (0.0)		Uncertain	5 (3.7)	5 (6.0)	0 (0.0)
Agree	1 (0.7)	1 (1.2)	0 (0.0)		Agree	4 (3.0)	4 (4.8)	0 (0.0)
The blood donation center staff were very friendly.				<0.001	Our hospital has a policy that all clients who fail the predonation screening tests are referred to a clinician for management.				0.111
Disagree	7 (5.2)	0 (0.0)	7 (14.0)		Disagree	127 (94.8)	77 (91.7)	50 (100.0)
Uncertain	12 (8.9)	0 (0.0)	12 (24.0)		Uncertain	5 (3.7)	5 (6.0)	0 (0.0)
Agree	116 (85.9)	85 (100.0)	31 (62.0)		Agree	2 (1.5)	2 (2.4)	0 (0.0)

GH: Government hospital; MH: Memorial hospital.

The data is presented as frequencies n (%) with statistical significance at p < 0.05 determined using chi-square test.

Communication issues regarding deferral status disclosures

In Table 3, the data were further explored to assess the communication issues regarding deferral status disclosures at the two blood collection centers. Overall, a little over one-third of the prospective blood donors confirmed that they were deferred. When the deferred donors were explored per blood collection center, proportionately more participants from Nagel memorial blood collection center were deferred compared to Bibiani government hospital blood collection center (60.0% versus 20.0%; p < 0.001). Overall, overwhelming majority (95.7%) of the deferred prospective blood donors knew their deferral status (63.8% temporary versus 31.9% permanent deferral). Notably, the knowledge of the deferred blood donors regarding their exact deferral status did not significantly differ between the two blood collection centers. Furthermore, a little over 4-in-10 of the laboratory professionals indicated that there were barriers to honest practitioner-blood donor interactions at the blood collection centers; disproportionately more laboratory professionals from the Nagel Memorial hospital laboratory raised concerns about barriers to honest practitioner-prospective donor communication (72.0% versus 21.5%; p < 0.001).

Table 3.

Disclosure of deferral status from perspectives of prospective blood donors and laboratory professional.

Variable	Total (%)	Bibiani GH	Nagel MH	p-Value
Prospective blood donors
What was the outcome of the screening process?				<0.001
I do not know	1 (0.7)	1 (1.2)	0 (0.0)
I qualified to donate	87 (64.4)	67 (78.8)	20 (40.0)
I was disqualified	47 (34.8)	17 (20.0)	30 (60.0)
What is your deferral status (if you were not allowed to donate)?				0.127
Temporary, I can donate after some time	30 (63.8)	11 (64.7)	19 (63.3)
Permanent, I cannot donate blood	15 (31.9)	4 (23.5)	11 (36.7)
I do not know	2 (4.3)	2 (11.8)	0 (0.0)
Laboratory staff
Are there barriers to honest practitioner-donor communication in this facility during the predonation screening process?				<0.001
Yes	53 (41.1)	17 (21.5)	36 (72.0)
No	76 (58.9)	62 (78.5)	14 (28.0)

GH: Government hospital; MH: Memorial hospital.

The data are presented as frequencies n (%) with statistical significance at p < 0.05 determined using chi-square test.

Participants’ perspective on postblood donation care

Participants’ knowledge was assessed with regards to postblood donation care practices at the two blood collection centers (Table 4). Both prospective blood donors (99.2%) and blood collection center staff (90.0%) indicated that the blood collection center do not provide any information leaflet advising donors on eating habits. Also, the prospective blood donors indicated that counseling about lifestyle choices to avoid are provided (84.9%) and was affirmed by the laboratory staff (96.9%). Furthermore, 9-in-10 of the prospective donors (88.2%) indicated that they were not directed to contact any focal person should they experience postdonation reactions; this was affirmed by 9-in-10 laboratory staff who stated that no focal persons are appointed to handle postdonation adverse events. Overall, less than 4-in-10 of the prospective donors indicated considering classifying themselves as regular blood donors; the participants from the Bibiani government hospital, however, were more disproportionately represented in those who considered the idea of classifying as regular blood donors (60.9% versus 8.0% participants from Nagel Memorial hospital). However, only a little over 1-in-10 (11.5%) laboratory staff indicated that their facility has a policy in place to use postblood donation follow text messages to retain successful blood donors. Moreover, more than half of the prospective donors indicated fully understanding the lifestyle choices required of blood donors (56.8%) or fully knowing about the blood donor eligibility criteria (51.3%). However, only 2.5% of the blood donors indicated being knowledgeable about the drugs that could disqualify prospective donors. With regards to the laboratory staff, less than half (42.3%) indicated that prospective donors with permanent deferral results are fully informed, compared to 58.2% who indicated discomfort when disclosing positive/reactive screening test results.

Table 4.

Prospective donors and laboratory professionals’ perspective on postblood donation care.

Prospective blood donors					Laboratory professionals
	Total (%)	Bibiani GH	Nagel MH	p-Value	Total (%)	Bibiani GH	Nagel MH		p-Value
I was given information leaflet to advise me on my eating choices after the blood donation				0.393	All successful blood donors are given information leaflet to advise them on eating choices after the blood donation				0.011
Disagree	118 (99.2)	68 (98.6)	50 (100.0)		Disagree	117 (90.0)	67 (83.3)	50 (100.0)
Uncertain	0 (0.0)	0 (0.0)	0 (0.0)		Uncertain	3 (2.3)	3 (3.8)	0 (0.0)
Agree	1 (0.8)	1 (1.4)	0 (0.0)		Agree	10 (7.7)	10 (12.5)	0 (0.0)
I was given counseling on what to avoid after the blood donation				0.969	All blood donors are given counseling on what to avoid after the blood donation				0.275
Disagree	7 (5.9)	4 (5.8)	3 (6.0)		Disagree	1 (0.8)	1 (1.3)	0 (0.0)
Uncertain	11 (9.2)	6 (8.7)	5 (10.0)		Uncertain	3 (2.3)	3 (3.8)	0 (0.0)
Agree	101 (84.9)	59 (85.5)	42 (84.0)		Agree	126 (96.9)	10 (12.5)	50 (100.0)
I was instructed to call a specified person if I experience any unusual changes in my body				0.003	We have a focal person that blood donors contact if they experience any unusual changes in their body				0.011
Disagree	105 (88.2)	55 (79.7)	50 (100.0)		Disagree	117 (90.0)	67 (83.8)	50 (100.0)
Uncertain	5 (4.2)	5 (7.2)	0 (0.0)		Uncertain	4 (3.1)	4 (5.0)	0 (0.0)
Agree	9 (7.6)	9 (13.0)	0 (0.0)		Agree	9 (6.9)	9 (11.3)	0 (0.0)
I will classify myself as a regular voluntary blood donor				<0.001	We have a policy in place to send follow up text messages to retain successful blood donors				<0.001
Disagree	58 (48.7)	17 (24.6)	41 (82.0)		Disagree	112 (86.2)	62 (77.5)	50 (100.0)
Uncertain	15 (12.6)	10 (14.5)	5 (10.0)		Uncertain	3 (2.3)	3 (3.8)	0 (0.0)
Agree	46 (38.7)	42 (60.9)	4 (8.0)		Agree	15 (11.5)	15 (18.8)	0 (0.0)
I now fully understand lifestyles choices that a blood donor should avoid				<0.001	All clients who have conditions that merits permanent deferral are fully informed as such				<0.001
Disagree	23 (19.5)	1 (1.5)	22 (44.0)		Disagree	68 (52.3)	22 (27.5)	46 (92.0)
Uncertain	28 (23.7)	19 (27.9)	9 (18.0)		Uncertain	7 (5.4)	3 (3.8)	4 (8.0)
Agree	67 (56.8)	48 (70.6)	19 (38.0)		Agree	55 (42.3)	55 (68.8)	0 (0.0)
I now fully understand the blood donor eligibility criteria				<0.001	I acknowledge that I am not comfortable disclosing positive results				<0.001
Disagree	34 (28.6)	2 (2.9)	32 (64.0)		Disagree	56 (41.8)	56 (66.7)	0 (0.0)
Uncertain	24 (20.2)	19 (27.5)	5 (10.0)		Uncertain	0 (0.0)	0 (0.0)	0 (0.0)
Agree	61 (51.3)	48 (69.6)	13 (26.0)		Agree	78 (58.2)	28 (33.3)	50 (100.0)
I can list some drugs that if a person is taking would disqualify him/her from donating blood				0.328
Disagree	109 (91.6)	62 (89.9)	47 (94.0)
Uncertain	7 95.9)	4 (5.8)	3 (6.0)
Agree	3 (2.5)	3 (4.3)	0 (0.0)

GH: Government hospital; MH: Memorial hospital.

The data are presented as frequencies n (%) with statistical significance at p < 0.05 determined using the chi-square test.

Discussion

Auditing of processes in the healthcare system enable healthcare professionals to identify actionable points/areas and continuously improve healthcare delivery.^9,10 Audit as a quality improvement strategy is particularly critical in sub-Saharan Africa, where the national blood services regularly fail to meet their annual blood donation requirement of 1% of their respective populations due to such factors as donor apathy, poor knowledge about blood donation processes, and failure to retain successful blood donors. Auditing of the entire processes of blood donor recruitment within the blood collection centers may provide important clues for blood donation service improvement.⁶ In this two-center mixed-methods study, we audited the blood donor recruitment processes from the researcher perspective (through observations) as well as through both prospective blood donors’ and laboratory staff perspectives as a step toward providing a comprehensive overview of the lived experiences of the blood donor recruitment process. Overwhelmingly, through researcher observations and affirmed by both laboratory staff and prospective blood donors, our study found a lack of standardization of the existing blood donor recruitment processes within the two facilities as there was no adoption of UDHQ, blood donor information leaflet, or medication deferral list during the blood donor recruitment process. Also, there was inadequate physical examination of prospective blood donors to the extent that parameters such as blood pressure, temperature, pulse and weight were not routinely assessed. Additionally, based on observations and prospective blood donors’ perspectives, the blood donor recruitment and donor experiences largely significantly differed between the two facilities which further argue for a lack of standardized processes that are implemented across the board in the blood donor recruitment processes. Moreover, none of the two facilities had focal persons that deferred prospective donors were referred to for counseling or for successful donors to contact should they experience any postblood donation adverse events. Taken together, given the lack of operationalization of standard operating procedures (SOPs), there is entrenched subjectivity of the prospective blood donor recruitment processes leading to variability in the blood donor experiences as well as poor postblood donation care at the two facilities.

Given the evidence that voluntary blood donors have reduced incidence of TTIs, the WHO has advocated for blood collection centers across the globe to strive toward 100% voluntary blood donation.¹¹ In the study reported herein, less than 1-in-10 of the prospective blood donors were walk-in voluntary blood donors compared to one-third being paid blood donors and nearly 6-in-10 being family/replacement donors. Previous studies have reported high deferral rates among nonvoluntary blood donors, which is in agreement with the relatively high deferral rate (34.8%) reported among the disproportionately high nonvoluntary blood donors in the present study.^12,13 Although this study did not explore community-based dwellers attitude toward intentional blood mobilization drives, and cannot therefore be taken to represent the entire picture of voluntary blood donation participation in the two communities, it is evident that walk-in voluntary blood donation has not attained the required traction within the two communities similar to a previous report from Kenya.¹⁴ Instructively, much public health campaigns are required to increase the awareness of these community dwellers about the important place for voluntary walk-in blood donations as a safeguard against acute blood shortage. It is noteworthy that a little over 9-in-10 (91.8%) of the prospective blood donors were <40 years (17–39 years). Considering that the two regions, in which this study was undertaken, have a majority youth population as per the recent Ghanaian demographic survey¹⁵ this should be encouraging that prioritizing blood donation educational campaigns toward these youths may likely lead to improved blood donation among them. In agreement with previous studies, the prospective donors at the two blood centers in this study were largely males (91.1%). Noteworthily, none of the prospective female blood donors were walk-in voluntary blood donors with 91.7% being family/replacement blood donors. Although the meager female blood donation contributions in sub-Saharan Africa may have sociocultural orientations,¹⁶ it is encouraging that some females are donating blood. However, future public health education ought to adopt strategies toward changing public perceptions to convert family/replacement female blood donors into voluntary walk-in donors.

An important step toward assuring the safety of donated blood is the privacy of the blood donor recruitment processes that ensure that prospective donors can freely divulge at-risk lifestyle information. Moreover, ensuring privacy at the blood collection center would likely enable prospective donors to discuss potential fears and misconceptions with the blood donation processes.^17–19 In our researcher observation data collection, we observed that the set-up of the blood donor recruitment/screening rooms did not assure adequacy of privacy since others (laboratorians and other prospective donors waiting for their turn) could eavesdrop in such conversations since there were no clearly delineated waiting areas. Not surprisingly, nearly half of the laboratory staff (41.1%) indicated that they perceived existence of barriers to effective practitioner-prospective blood donor communication in agreement with a previous study in a similar setting.²⁰ As further evidence of the need to address these privacy issues, whereas less than half (42.3%) of the laboratory professional indicated that all clients with conditions meriting permanent deferral were fully informed as such, close to 6-in-10 of these laboratory professionals (58.2%) indicated being uncomfortable disclosing positive predonation screening results to clients. This was consistent with the researcher observations in which only occasionally did the laboratory staff disclose the exact reason for the prospective donor deferral, mostly in response to the curious probing of the deferred prospective blood donor. It is instructive to note that, contrary to recommended practice,^21,22 none of these facilities had clinical transfusionist/notifier as part of the blood donor recruitment team, nor did they have a dedicated clinician or trained clinical staff to handle predonation screening results disclosures or even postdonation adverse events. This is an obvious gap in the composition of the existing blood donor recruitment team that ought to be addressed to improve the service delivery at the study sites.

Our study found the predonation processes to be characterized by a lack of adherence to SOPs as each of the two facilities fails to adopt the UDHQ, and has neither in-house medication deferral list nor blood donor information leaflet to assist in the screening of prospective blood donors.²³ The UDHQ has globally been employed to standardize predonation screening to foremost safeguard blood donor health as well as protect the potential blood recipient from TTIs.²⁴ In failing to adopt these, we observed a considerable intrafacility and interfacility variability in the practitioner-prospective blood donor interactions in terms of what predonation questions are asked of the prospective donor, the timeframe taken for the practitioner-prospective donor predonation screening as well as even how postscreening information are relayed to the prospective donor. In practical terms, this translated into significant differences in the self-disclosed experiences of the prospective donors. For example, regarding prospective blood donors’ satisfaction with the explanations to their questions asked during the predonation screening stage, disproportionately more prospective donors from Bibiani government hospital laboratory felt that their questions were adequately answered compared to those from Nagel memorial hospital. As further evidence of the varied experiences and service provision, whereas only one-third of prospective donors at the Nagel Memorial hospital indicated willingness to consider re-donating blood in the future, an overwhelming 98.9% of prospective blood donors at the Bibiani government hospital were willing to re-donate blood if given the opportunity in the future. Although the study design was such that we could not explore the reasons for this disparate willingness to consider future blood donations, we are inclined to suppose that, in addition to the varied experiences at facilities, the considerably higher proportion of deferred donors from the Nagel Memorial hospital (60.0% versus 20.0% as compared to Bibiani government hospital) could have been a contributory factor. We recommend further research to explore the relatively high rate of favorable responses from the participants from the Bibiani government hospital, as it may unearth practices that could be harnessed to assure blood donor satisfaction and perhaps boost donor retention. Disturbingly, despite the willingness of the prospective donors to consider future blood donations, overwhelming majority of the laboratory professionals (86.2%) disclosed the lack of intentional blood donor retention strategies such as text messaging individuals with prior successful blood donation to retain these to become regular voluntary blood donors. This surely represents a missed opportunity toward meeting the 100% voluntary blood donation target as intentional regular usage of social media platforms have been shown to improve blood donation prospects elsewhere.^25,26 Interestingly, these disparate experiences were also corroborated by the responses of the laboratory professionals. For example, although more than 80% of the laboratory staff in each facility indicated that efforts were made to answer questions asked by the prospective donors, only 20% of laboratory professionals from the Nagel Memorial hospital (versus 98.8% from Bibiani government hospital) indicated explaining all the blood donation procedures to the prospective donors. Taken together with a previous study in the Central region of Ghana that explored laboratory professionals–patient interactions using mixed methods approach,²⁰ the nonadherence to standard operating protocols to regulate practice may be entrenched in the laboratory service delivery in the healthcare system across much of the country.

Evidently, the postdonation care at the two facilities needs quality improvement initiatives to improve donor satisfaction and as well as donor retention. Although more than half of the prospective blood donors (56.8%) indicated knowing the lifestyle choices to avoid, or knowing the donor eligibility criteria (51.3%), the postdonation phase was also characterized by intrafacility and interfacility variability of service provision because of the nonexistence of standard operating protocols. There was no formalized blood donor information leaflet to instruct successful donors on eating habits or lifestyle choices post donation. Moreover, although some studies have documented adverse postdonation reactions^27,28 that might require assistance and care of a member of the clinical team, none of the facilities had a focal person assigned for these duties. Overwhelmingly, both laboratory professionals (90.0%) and prospective donors (88.2%) indicated the nonexistence of focal persons that could be contacted to handle postblood donation adverse events.

Taken together, the lack of operational standard operating protocols regarding use of the UDHQs, medication deferral list, or donor information leaflet both at the predonation and postdonation period may have negative consequences for both donor and prospective blood recipients. Evidently, one may not be wrong in supposing that with the variability of service provision inherent in the existing status quo at each facility, some prospective donors who might be on medications that warrant deferral might filter through and donate blood. Moreover, a critical role played by the adoption of UDHQ is to afford prospective blood donors the option of self-exclusion should they have engaged in any lifestyle activity flagged in the UDHQ or exposed to any condition that could jeopardize the health of the potential blood recipient. Obviously, issues of literacy levels may be an anticipated challenge in decisions to implement standardized donor information leaflets, UDHQ usage, and medication deferral lists. This therefore calls for a need to have trained laboratorians or blood donor recruitment team with language competencies in English (which is ensured in the educational system) and indigenous language competencies to ensure that adopted standard protocols are adequately and competently translated into the required dialects during the recruitment process to ensure friendly service provision for both formally and nonformally educated individuals. This is more so considering that close to 1-in-5 (18.6%) of our prospective blood donors had less than secondary education and might have challenges with comprehension if all the predonation information were delivered in English.

Limitations

Although our blood donor recruitment audit study has provided empirical data regarding the state of practice at the two facilities, we acknowledge that our study was undertaken in two facilities and may not necessarily give the overall representation of donor recruitment in Ghana. Also, the fact that we concentrated on facility-based blood donations is indicative that what is reported herein cannot be taken to necessarily characterize attitude or perceptions regarding mobile blood donor recruitment drives. Furthermore, given the general low blood donation rate, we could neither deploy a probability sampling technique nor power calculations in sample size estimation in our data collection to minimize bias and assure generalizability. In spite of these acknowledged limitations, our study enabled us to observe and reflect on the prevailing blood donor recruitment practices at the two facilities and has highlighted the lack of SOPs to streamline the blood donor recruitment processes at the two blood collection centers. As this is only an aspect of the audit cycle, further explorations are required to establish the depth of such practices in the various blood collection centers across the country.

Conclusions

The lack of operational SOPs may occasion inter- and intrafacility variability of blood donor recruitment practices. Also, focus group discussions and interactive presentation-based educational training of the laboratory staff at the study sites may be required as part of a continuous professional development strategy to orient them in globally standardized blood donor recruitment guidelines/procedures. Furthermore, there is a need to strengthen the blood donor recruitment team through the inclusion of a transfusionist and/or focal clinical person to coordinate the predonation screening results disclosure and postblood donation care. Moreover, interventional implementation research may be required to improve pre- and postdonation services offered to both successful and deferred donors in the study settings, as well as minimize the variability of blood donor recruitment practices.

Supplemental Material

sj-docx-1-smo-10.1177_20503121251380641 – Supplemental material for Lack of standardization of blood donor recruitment processes: A two-center mixed-methods audit study in Ghana

Supplemental material, sj-docx-1-smo-10.1177_20503121251380641 for Lack of standardization of blood donor recruitment processes: A two-center mixed-methods audit study in Ghana by Daniel Baah, Joseph Kofi Amponsah, Ama Gyasiwaah Owusu-Poku, Joseph Boachie and Patrick Adu in SAGE Open Medicine

Supplemental Material

sj-docx-2-smo-10.1177_20503121251380641 – Supplemental material for Lack of standardization of blood donor recruitment processes: A two-center mixed-methods audit study in Ghana

Supplemental material, sj-docx-2-smo-10.1177_20503121251380641 for Lack of standardization of blood donor recruitment processes: A two-center mixed-methods audit study in Ghana by Daniel Baah, Joseph Kofi Amponsah, Ama Gyasiwaah Owusu-Poku, Joseph Boachie and Patrick Adu in SAGE Open Medicine

Footnotes

Acknowledgements

We are grateful to the management of the Bibiani Government hospital and Nagel Memorial Adventist hospital for permitting us to undertake the study within their respective premises. We are also grateful to all participants who volunteered for the study.

ORCID iDs

Ama Gyasiwaah Owusu-Poku

Joseph Boachie

Patrick Adu

Ethical considerations

Ethical approval for this study was obtained from the Institutional Review Board of the University of Cape Coast (ID: UCCIRB/CHAS/2022/75). Additionally, approval to conduct this study was sought from the Medical Superintendents of each of the Bibiani Municipal hospital and Nagel Memorial hospital. Our study protocol conformed to the provisions of the Declaration of Helsinki in 1995 (as revised in Brazil 2013) including confidentiality, risks, and benefits assessments, consent to participate, and ensuring respect to participants.

Consent to participate

Written informed consent was obtained from all subjects before the study. Additionally, since the age of consent in Ghana is 18 years, written informed consent was obtained from legally authorized representatives before the study (for subjects <18 years). For participants with no formal education, the study protocol, the purpose of the study and the voluntary participatory nature were explained to them using the local language (Twi); those who agreed (n = 4) to be part of the study were required to thumb-print the consent forms before being enrolled into the study.

Consent for publication

Not applicable.

Author contributions

P.A. was involved in conception and supervision, project administration, quantitative data analyses, qualitative data analyses, and writing the original article draft. D.B. and J.K.A. were involved in participant recruitment, questionnaire administration, questionnaire data entry, and validation. J.B. and A.G.O.-P. were involved in project supervision, observation data collection and transcription, and critical review of the article. All authors read and approved the final article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability statement

The raw de-identified dataset used and/or analyzed during the current study is available from the corresponding author on reasonable request.

Supplemental material

Supplemental material for this article is available online.

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