Knowledge, attitudes and practices related to blood donation in a selected population in Jaffna

Poor knowledge and negative attitudes among the public regarding blood donation have resulted in insufficient availability of blood and blood products for transfusion procedures in many clinical settings. This study aims to assess knowledge, attitudes and practices related to blood donation and their associated socio-demographic factors in Jaffna. A descriptive cross-sectional study was carried out among service-users at the Motor Traffic Department, District Secretariat, Jaffna, between 12 noon and 4 pm during a six-week period. Data were collected through an interviewer-based questionnaire. Frequencies, proportions, and the Chi Square test were used to analyze the data with SPSS (v25). The critical level was set at 0.05. A total of 300 service users participated; of them, most were females (59%), between 18 to 39 years (77%), with at least O/L qualifications (90%). Knowledge on eligibility criteria for blood donation was low compared to knowledge on risk behaviors that rendered them ineligible. Although an overwhelming majority (96%) believed that people should donate blood, only 21% had donated once in their lifetime. The most common reason for not having donated blood was that they had not been approached for blood donation (42%). Male gender (p<0.001) and being employed (p=0.013) were significantly associated with having donated blood. Knowledge gaps exist even among a fairly educated population in Jaffna. Attitudes on blood donation seem favourable, although practices are poor. Blood donation campaigns should address knowledge gaps and actively recruit the public for blood donation. Strategies should be developed to encourage voluntary blood donation.

A total of 300 service users participated; of them, most were females (59%), between 18 to 39 years (77%), with at least O/L qualifications (90%). Knowledge on eligibility criteria for blood donation was low compared to knowledge on risk behaviors that rendered them ineligible. Although an overwhelming majority (96%) believed that people should donate blood, only 21% had donated once in their lifetime. The most common reason for not having donated blood was that they had not been approached for blood donation (42%). Male gender (p<0.001) and being employed (p=0.013) were significantly associated with having donated blood.
Knowledge gaps exist even among a fairly educated population in Jaffna. Attitudes on blood donation seem favourable, although practices are poor. Blood donation campaigns should address knowledge gaps and actively recruit the public for blood donation. Strategies should be developed to encourage voluntary blood donation.

Background
Blood transfusion is a lifesaving clinical procedure in both routine and emergency situations. Many common conditions such as anemia, bleeding disorders, complications of childbirth, surgery and trauma require blood transfusion. The only source of blood products used in blood transfusion procedures are human donors; no substitute has yet been discovered. [1] Voluntary donor blood is associated with a significantly lower risk of transmitting infections. [2] To ensure a continuous supply of safe blood and blood products, there needs to be a critical mass of voluntary blood donors, in turn, requiring a knowledgeable population with favorable attitudes and practices of donation. [3] The rate of blood donation in low-and middle-income countries is estimated to be 18 times lower than in highincome countries. [4] Myths, misperceptions and ignorance are known to instill fear, anxiety and an overall negative attitude towards blood donation. [2] Various sociodemographic factors, including gender, age, education and occupation, are known to be associated with knowledge, attitudes and practices regarding blood donation. [1,2,5] In Sri Lanka too, the National Blood Transfusion Service relies 100 per cent on voluntary blood Knowledge, attitudes and practices related to blood donation in a selected population in Jaffna Ziyard S 1 , Amarasingam S 1 , Sangaralingam K 1 , Gamage PK 1 , Sosai ST 1 , Kumar. R 1 , Seneviratne D 2 , Sooriyakumar, T 2 . 1 Faculty of Medicine, Jaffna, 2 Teaching Hospital Jaffna donation from non-remunerated regular blood donors. [6] While some misconceptions, fears and knowledge gaps are identified among the public in some parts of Sri Lanka, overall rates of blood donation among eligible persons are known to be poor, where male gender, younger age, higher education and being employed are identified to be associated with the practice of donation. [5,7,8] Experts in the health sector of the Northern Province report shortfalls in voluntary blood donation in Jaffna. While it has been suggested that citizens fear donating blood owing to myths and misconceptions, systematic studies on this topic have not been undertaken.
The District Secretariat Jaffna is accessed by citizens representing a wide social spectrum. The Motor Traffic Department in the Jaffna District Secretariat is usually visited by young and middleaged persons applying for vehicle licenses from all parts of the district, and thus represents an ideal setting to capture the knowledge, attitudes and practices regarding blood donation among the age group eligible for donation in Jaffna. This study aims to assess knowledge, attitudes and practices related to blood donation and their associated factors among service users at the Motor Traffic Department of the District Secretariat, Jaffna.

Methods
This descriptive cross-sectional study was conducted amongst service users at the Motor Traffic Department of the District Secretariat, Jaffna, in 2020/2021. The required sample size was 377. Consecutive sampling was used to recruit 300 consenting adults less than 60 years accessing services at the Motor Traffic Department from 12 noon to 4 pm on weekdays during the 6-week data collection period. Data collection was terminated prematurely owing to the COVID-19 pandemic.
Data were collected by an interviewer-administered questionnaire developed by the investigators based on information from the National Blood Transfusion Service. [9] and World Health Organization. [10] Content and face validation were assessed by a consultant hematologist and a consultant transfusion physician. The questionnaire was designed to elicit information on sociodemographic factors, knowledge, attitudes, practices and reasons for not donating blood. The questionnaire was translated to Tamil and checked against the English version by two bilingual members of the research team, and pre-tested on 10 persons visiting the Nallur Divisional Secretariat, Jaffna.
Data collection was carried out by the investigators in the waiting area of the Motor Traffic Department. The purpose of the research was explained prior to data collection and informed written consent obtained from the participants. Privacy was ensured owing to physical distancing requirements during the pandemic.
Data were entered into a password-protected personal computer and analysis was performed by using the Statistical package for Social Science (SPSS 25) software. Frequencies and percentages were used to describe the variables. The association between selected sociodemographic factors and practices was assessed using the Chi Square test. The critical value was set at 0.05. Tables and charts were used to present the data.
Ethical clearance was obtained from the Ethics Review Committee, Faculty of Medicine, University of Jaffna, and written permission to collect data was obtained from the District Secretary of Jaffna.

Sociodemographic characteristics of the sample
In total, 300 service users at the Motor Traffic Department participated in the study. The mean age of the sample was 31.3 years (SD 10.3) with a median of 29 years (IQR 23-38). The sample consisted mostly of females (n=178, 59%) between the ages of 18 to 39 years old (232, 77%), mostly Hindu (n= 241, 80%). With regard to education level and employment, 90% (n=269) had at least O/L qualifications, and a considerable proportion were employed (n= 137, 46%). Only 9 (3%) reported being health care workers. Over half of the sample resided more than 10 km away from the Teaching Hospital Jaffna (n= 163, 54%). (Table 1)

Knowledge regarding blood donation
In the sample, only 28% (n= 85) were aware of the correct eligible age group (18 years to 60/65 years), while 43% (n=129) was aware of the minimum weight (50 kg) to be a blood donor. Most participants knew that pregnant mothers could not donate blood (n=228, 76%) but many were not of the knowledge that menstruating women were eligible to donate blood (n=244, 81%). A considerable proportion were aware that donors with common disease conditions such as diabetes mellitus (n=205, 68%) and hypertension (n= 196, 65%) could donate blood, while only 55 (18%) were aware that those with hyperlipidaemia could donate blood. Majority were aware of the groups of people who were ineligible to donate blood such as sex workers and their clients (n= 265, 88%), injectable drug users (n=265, 88%), those who have multiple sex partners (n=222, 74%), and those who arrive immediately after alcohol consumption (n=236, 79%) ( Table 2).

Attitudes regarding blood donation
In the sample, a large majority responded favourably towards the statements "people should donate blood" (n= 287, 96%) and "blood donation is a national duty" (n=252, 84%). In fact, 241 (80%) said they would like to donate blood in the future, and 266 (89%) believed they should motivate family and friends to donate blood. However, 130 (43%) said they would be willing to donate blood only in emergencies, while 119 (40%) preferred to donate only to family and friends.

Practices of Blood Donation
In the sample, only 64 (21%) had donated blood at least once in their lifetime (Table 3). Among them, 31 (48%) had donated blood at the blood bank, 19 (30%) had donated at a blood donation campaign, and 18 (28%) had donated at a mobile camp. Amongst the 64 ever donors, only 24 (38%) individuals had donated 3 or more times in their lifetime. Furthermore, when considering the last donation, only 21 (33%) had donated blood in the 12 months (Table 3).

Discussion
The sample was relatively young with a mean age of 31.3 (SD 10.3 years) and represented a fairly educated working population. Over half (52.3%) had educational qualifications above G.C.E Ordinary Level, while 45% reported current employment.
We identified several knowledge gaps regarding blood donation. Although participants were aware of the conditions that made individuals ineligible for donation, they were not as familiar with the eligibility criteria. Less than half the sample knew the eligible age group (28%) and minimum weight (43%) required for blood donation. Over 80% of the sample responded that patients with hyperlipidemia (82%) and menstruating women (81%) could not donate blood. While this lack of familiarity with eligibility criteria may act as a barrier when one wants to volunteer for donation, misconceptions about menstruation may perhaps explain the low proportion of women in the group of blood donors.
A striking majority (96%) responded favorably that people should donate blood, that donating blood is a national duty (84%), and were willing to donate blood in the future (80%). This is in contrast to studies carried out in other settings where unfavorable attitudes were more common.
For instance, a study from Saudi Arabia found that lack of altruism was a barrier for blood donation. [11] In Sri Lanka, a study among donors from Galle found that the main reason for lack of re-donation was that there were no benefits of donation for the donors. [8] In Jaffna too, a substantial proportion in the present study were willing to donate only in an emergency (43%), and to family and friends (40%), suggesting that fewer may act on their stated intention to donate in the future.
Indeed, in the present study, 236 participants (79%) had never donated blood. Amongst those who did, only 24 (38%) individuals had donated 3 or more times in their lifetime. Furthermore, when considering the last donation, only 21 (33%) had donated blood in the 12 months. This is consistent with the findings of previous studies that suggest that favourable attitudes do not necessarily drive the public to donate blood. Positive attitudes not being reflected in blood donation practices has been shown to be a common theme in resourcepoor settings. [3] A study from Batticaloa among the public concluded that although knowledge and attitudes on blood donation were at a reasonably good level, various barriers impeded donation. [5] The most common reason cited by participants for not donating blood was that they were not approached for blood donation (42%). This is similar to a study from Saudi where the majority of non-donors (42%) stated that they had not donated blood because nobody approached them. [11] This may indicate the need for blood donation campaigns to actively recruit eligible members of the public, especially the younger working population, for blood donation in Sri Lanka.
We found a significant association between having donated blood and gender (p<0.001), where males were more likely to have donated blood. As most participants believed that menstruating women were not eligible for blood donation, taken together, our findings suggest that blood donation campaigns may need to target women specifically through gender-specific messages. The association between gender and blood donation varies by context where women are more likely to donate in some countries.
[12] but less likely to do so in most settings. [13,14] Employment was found to be significantly surrounding it is even more important.

Conflicts of interest
There are no conflicts of interest.