To donate or not donate, that is the question: an analysis of the critical factors of blood donation

Currently, in Brazil, 1.78% of the population area blood donors, a level lower than the ideal one that, according to WHO, should be between 3% and 5% of the population. Following this scenario, the current study has a general goal of identifying and analyzing the main critical factors of the process of blood donation in the city of Belo Horizonte, MG, under the perception of donors, potential donors and non donors. A qualitative research approach was conducted, through twenty-four semi-structured interviews. The results highlight the lack of information in the various stages of the blood donation system. During the stages of donor recruitment and awareness, communication actions convey to society incomplete information about the donation process, discouraging future actions of donation. On the other hand, a lack of appreciation of the donation experience and the construction of social values associated with the donor prevent the multiplication of social behaviors for donation. The results of this study, found from theoretical framework outlined in this study, highlight the causes or critical factors that impede changes in behavior, incremental or radical, proposed by social marketing.


Introduction
An exponential growth in demand for blood donations has been identified worldwide in the last decade, including in Brazil.Currently, approximately 1.8% of the population are blood donors 1 , but according to recommendations, the ideal index should be between 3% to 5% 2 .According to the propositions of Brazilian law, the act of donating blood is entirely voluntary and anonymous, not allowing any type of retribution 1 .
In the country, between the years 2012 and 2014, the average number of blood samples taken was 3,613,930 procedures annually 3 .If considering the year 2014, 94% of these were conducted by the Unified Health System (SUS) and 6% by purely private services.Currently, the total haemotherapic services performed in the country, 61.43% are carried out by public centers, 31.69% by centers affiliated with SUS and 6.87% exclusively private 1 .
In this context, social marketing emerges as an opportunity to contribute to the new donor recruiting process.The term social marketing was coined by Kotler and Zaltman 4 , to refer the use of techniques derived from conventional marketing towards social issues.According to this proposition, it is emphasized that social marketing has in its genesis, the attempt to maximize society's "welfare" [4][5][6][7][8][9][10][11] .
Social marketing can be understood as the use of commercial marketing techniques with the purpose of influencing a specific audience, voluntarily, to accept, modify, reject or abandon certain behavior in favor of social welfare, which can be a social cause such as blood donation, for example 12,13 .It is noted that this change in behavioral patterns begins in individual limits and evolves to collective levels 14 .In short, social marketing induces a behavioral change in individuals in an attempt to achieve social change, with the action focus on thought patterns of society and their respective evolution in order to meet the emerging needs of the group, by relational variations between people, groups, organizations and societies 15,16 .
Social change does not always occur in a planned way, this process can begin as individuals perceive that something is in disagreement with their individual or collective needs 17 .Since the process of social change begins at individual levels, it is important to understand the various factors that are constraints to the individual decision-making, among them, we emphasize the motivational and experiential aspects.
The motivation, according to Ferguson 18 has a complex conceptual delimitation.For the author, it is easier to identify a motivated individual than to conceptualize motivation in itself.So the authors point out that motivation is an individual and intrinsic process that is directly associated with the 'why' of the implementation of any particular action [18][19][20][21][22][23][24][25][26] .
Rogers et al. 23 point out that whenever an individual feels the need for something, whether physical or not, a state of motivation is identified.The need, therefore, can be recognized as a central variable to the motivation process 11,23,[27][28][29][30][31] .
For the authors referenced in this study [32][33][34][35] , the reasons that generate the needs are psychosocial phenomena, understood as relations established between the individual and the environment that surrounds it, while needs can be understood as physiological impulses that trigger actions of individuals.
In regards to the motivation for voluntary acts, for example, blood donation, despite the existence of the subjective aspect involving the subject during the practice of voluntary acts, it is possible to identify a general default behavior of these individuals, and their actions are conditioned, in the first instance, for the possibility to engage in third-party troubleshooting 34 , and these individuals act in search of indirect personal benefits 36 .In addition, voluntary action is justified, at the individual level by allowing a temporary shutdown by the individual of tensions generated in other spheres of their personal and social life 37 .
A motivated behavior emerges with the recognition of the existing and potential need of the individual, and in this cognitive space, motivations direct action in order to fill that need 38 .In this sense "man is a longing animal and rarely reaches the state of full satisfaction, except for a short period of time.Once a desire is satisfied, another explodes and takes its place" 26 , which characterizes the process as cyclical.
When considering the experiential aspects, according to some authors, goods, services and actions are used by individuals towards self-unravel, to create social images, feelings of belonging to the association of groups, and to the dissociation of other groups, creating identities or attributes of other meanings to existing identities [39][40][41] .
According to this approach one can attribute initial experiential aspects and unique structures, to those that encompass the experiences of different natures 42 .Among these there are the emotional, sensory, physical, cognitive, creative and social experiences.Therefore, the experien-tial aspects can be understood as the result of the convergence of several factors, composing in a holistic and hybrid manner.
From the foregoing theoretical design above, which demarcates the motivational and experiential aspects involved in voluntary and linked to social cause actions, this study aims to answer the following research problem: what are the critical factors in the decision to donate or to not donate blood?
The general objective of this study aims to identify and analyze the most critical factors in the blood donation process, from a sample of participants from the city of Belo Horizonte, MG, considering the perception of donors, potential donors and non-donors of blood.

Blood donation
Only 1.78% of the Brazilian population are blood donors 1 , 1.22% below the 3% ideal index.In the composition of this percentage the midwest (2.55%) region of Brazil stands out as most contributing to that percentage, followed by the southern region (2.28%) and the southeast (1.69%), as shown in Table 1.
In this scenario, it should be considered that the situation of blood banks becomes more critical during holiday periods and the end of the year, since there is growth in demand for blood transfusions and reduction of 20% to 25% in the number of donations made throughout Brazil 43 .
The blood donation process involves a rigorous system called 'Blood Cycle' , divided into nine steps: recruitment of donor, awareness, registration, clinical screening, hematological screening, blood collection, laboratory screening of blood samples, distribution and transfusion procedures 44 .
The process starts with the recruitment phase, which comprises a set of actions to raise awareness and educate the society for voluntary and continuous donation.The second stage is awareness, in which the possible candidates who have never donated blood or those who are more than two years without donating receive information and guidance on the whole process.Then registration occurs, at which time a form is filled out with identification information from the possible donor 45,46 .
Advancing in the process the stage of clinical trial begins.In this phase the doctor performs a physical assessment of the candidate and the questionnaire.
In the stage of hematological screening a drop of the candidate's blood is collected to veri-fy if he or she is anemic.If the test is positive the donation should be delayed until the individual is cured of anemia 47,48 .
According to Gontijo 45 , the sixth stage of the process is the collection of blood, in which the candidate donates approximately 450 ml of blood, which will then pass through laboratory screening.
The process of donating blood includes a series of legal requirements that must be met for the process to be complete.Among them, an important requirement is that the potential donor must have a weight exceeding 50 kilograms and must be aged between 18 and 67 years old.In some cases applicants are accepted for blood donation when aged 16 and 17, with the formal consent of the legal guardian 43 .
It is recommended that the donation candidate rest for at least 6 hours the night before; does not drink alcohol within the 12 hours prior; does not smoke cigarettes for at least 2 hours before donation 43 .

Method
This research was constructed in the light of a descriptive qualitative approach.The choice of approach is explained because the researchers worked with subjective perspectives in the world of meanings, beliefs, motivations, experiences and factors that have a representation of a space in the world of relations that cannot be operated quantitatively 49,50 .
Data were collected through the application of semi-structured interviews with twenty-four subjects that met the selection criteria, which for this study were frequent donors, non-donors (those who deliberately say they have never donated and will not donate blood), potential  245,782  1,431,673  656,690  3,586,523   Table 1.Blood donation rate by Brazilian region (2012).14,993,191  55,794,707  16,983,484  84,465,570  28,795,762  201,032 donors (i.e.those who have donated, but abandoned the behavior and those who have never donated, but could become donators) and individuals who have performed blood transfusions.

Population/IBGE
Participants were selected through the methodological technique known as snowball.According to Baldin and Munhoz 51 the methodology is not probabilistic, whereby individuals who participated initially in the research indicate new entrants and so on, to the point of saturation, which for this study was twenty-four individuals.
All participants had consented to the interview and academic treatment of the information, which was recorded in the individual recordings.To ensure the anonymity of participants it was agreed that they would be identified as E1, E2, ..., E24.The characterization of the participants is shown in Chart 1.
Following the collection, the data was organized and analyzed using content analysis tech-nique in the light of Bardin's 52 propositions.For this, we used the following analysis dimensions: critical factors of the blood donation process; the clinical and hematological screening and reasons for non-donation.

Presentation of results
The analysis of data collected through the interviews initially showed a failure in relation to the effectiveness of campaigns for motivation and attracting donors.According to participants campaigns do not adequately clarify the requirements for donation and do not demystify the "fears" related to blood donation.These factors were mentioned by non-donors and potential donors, highlighting the lack of motivational elements that reverse the decision to not donate blood.
Source: Research Data (2015).Fear, fear of pain, fear of catching the disease, fear as well, but are "n" factors that make a person afraid, fear is a factor, and lack of information would be another (E4 Potential).
They are, they are ... they give little information because like I told you, people often do not donate because of fear, right, for fear of risk, fear of disease, its ... knowing, not knowing where that blood will go, because many of them donate blood [...] sometimes the person donates blood they do not make precise tests before (E5 non donor) Information and clarification during the recruitment and motivation stages of blood donors could minimize the fear in relation to process safety, but in addition to a lack during campaigns, these show a lack of sensitivity to engage and a low frequency to sediment initial behaviors of donation.
Oh, I think it´s a lacks of sensitivity.When I see that campaign that way it does not sensitize me, I think it´s a lacks of sensitivity (E10 non donor).
I think that who the donor is, who likes to donate, I think even when he sees, if he is not remembering, he remembers and will donate.After it passes and you no longer see the campaign so often in the media, so I think that the campaigns should be more frequent (E16 non donor).
Another critical point related to campaigns is the deficiency of information that would allow for donations.On the one hand, at the time of recruitment, the blood donation campaigns transmit information that to be a blood donor one must be of adult age, in good health and weigh over fifty kilos.Then, the moment that the registration of a potential donor begins, other impediments are identified, which were not previously explained.This is a disincentive factor as evidenced by feeding a negative judgment of the entire process.
I had reports from my friends who were 'super' disappointed.One was a drug user, then arrived there in screening and found he could not.So how is this not disclosed?People are embarrassed, for example, even when he is not a user, and time has passed, will he have the motivation to go back there?(E7 potential).
It I donated blood because I always thought it was a cool thing, a supportive attitude, people need to donate blood.I stopped because of the bureaucracy of the system itself, I was already a donor.I was impeded four times in a row, because I had gone to the dentist, then had taken medicine, then had gotten the flu, so I went and could not donate.The problem is that this is never told, and how it happened, so a few times in a row I was prevented, then that habit that I had, I ended up losing (E4 Potential).
On the other hand, it is identified that a significant portion of the impediments in the steps of the donation process are related to the clinical and hematological screening.This screening process is identified as an important and valid step by participants, since it allows the identification and selection of suitable donors.
We make the donation and then they will evaluate, even to avoid rework.Because if I go there to do the assessment and then return to make the donation it would be a step backwards, then you run the risk of completing all the work and the blood not be used (E23 Donor).
Note also that some participants point out that the strategy of widespread dissemination of the need to donate blood and subsequent filtering of those donors that are able to donate generates an opposite result, as discouraging potential donors who temporarily are not able to donate preventing their future donation.
For me this is a simplification of information, they try to draw a lot of people to donate and then the screening blocks everyone.Did not they realize that this is a shot in the foot?(E1 Donor).
I also think they should be clearer to explain why barred people cannot donate, because, sometimes, the thing so silly that can be avoided in a future donation.So I think that had to improve this process, this screening (E9 Potential).
The lack of information identified as well as the recruitment for donation is evidenced by one participant as a justifying factor for screening, seen as positive and important.
I find it's very important, there are people who have no knowledge of you or your health.I think it has to have the same screening to check, the blood needs to be checked even if we do not pass things to people and can aggravate further their health (E6 Donor).
Therefore, it is believed that the screening process done in two stages, through questionnaires, with an attendant at the first stage and a doctor at the second, is seen in a bureaucratic way and it could be unified with the stage of service and medical evaluation.
I think that what obviously turns a lot of people away is that questionnaire they give us.The questionnaire has about sixty questions, I went through two, I went through one and then went through another, that was with the doctor.I think it had to be only with the doctor (E9 Potential).
Another important point to note concerns the issues related to the perception of security of both the donor and the recipient's blood.Such questions may be observed, particularly during the screening process that despite widespread awareness of its importance, still raise questions about their level of security.The perception of insecurity is indicated both by donors and by potential donors who have donated, but abandoned this behavior.
I find it very important and fundamental the screening, but even so, the donor can fool a professional.[So you think it's not a safe process?] 100% unsafe in any way (E24 non donor).
I found it a flawed process because I remember one little question of yes or no that you have to answer at the end.You go through a screening with a huge number of questions at the end, after the donation, you still have to confirm that you think your donation is able or not to be passed on to those who are in need.That yes or no, and you have passed the screening, has collected the blood, you have to answer again generated doubt there.I went to ask an official and the justification she gave me made me understand that the process is not guaranteed, mainly for those who will receive the blood.I thought it was flawed, totally flawed.[In what sense?]In that it was made understood that the patient may be infected by receiving blood and this caused me a lot of questions about the safety of the process, especially of the screening (E11Potential).
One issue that seemed relevant in assessing the blood donation process, but that is not directly related to evaluation of this is the perception of recovery and social prominence given to donors.In general, regardless of donor status, non-donor and potential donor, a lack of social appreciation of the blood donor it is identified.The act of donating blood among participants is only appreciated by those who receive the blood, and the circle of friends and family directly involved with receiving blood.
In advertising yes, but not in real life.You talk to people, ah ... I went there to donate blood, for many people it is a good thing you did, but it is not valued.Not that it is not valued, but does not have much, it's warm, it's kind of amorphous (E6 Donor).
No. I do not think it is socially valued, it has value only to the person receiving.Because the person who is there is very indifferent, so I do not think it is valued in any way, it's who is there, the family, the person that is there receiving at the moment that they are in need, because he/she gives value to things, gives value to the donor (E9 Potential).
For some participants the lack of value for the blood donor, besides being a social behavior, is also an individual act, under which the motivation for giving is not based.
No.But I think who also donates not want to be recognized not, he gives because he wants to go there and do this act, because he is good, because he wants to do good or because he wants to donate blood to someone he knows.Nobody does because he wants to be recognized not, "Oh, I'm blood donor," not.(E3 not donor).
Identifying critical factors of non-donors of blood also implies understanding the factors that motivate those who donate.For declared donors and potential donors who have donated and currently do not donate blood, the main motivational factor was the need to donate for an acquaintance by the donor or a request by a known person relatives or friends who needed the donation.On the other hand, the intrinsic and individual satisfaction of the donor is activated, reinforcing the social gain from doing good to someone close.Even though the donation process is indirect, that is, the donated blood is not allocated directly to the person who motivated the donation; the encouragement made by an acquaintance awakens altruistic motivation and jointly provides the act of giving.
The first time I donated it was a friend who needed it, then he asked us to go and I thought 'super' interesting and went.I think it's a feeling like of help, right?To contribute with someone else.[The second time was how?]The second time was the father of a brother who went to have a surgery, so I went.Both times I was asked to donate (E15 Potential).
It is an experience for you to make an offer, for you be useful, for you to contribute with someone, therefore it is a pleasurable experience, you can offer what you have for someone who is in need, be it temporary, you can contribute, you can donate, so it is very worth it (E6 donor).
Look, I think the main issue is to understand the need, when you are near, when with a family member it has already happened, I think I stop to think about it.I also think that the influence of friends, donors greatly influence the environment in which they operate, I think it's more for these same strands (E7 potential).
Other participants indicate different grounds for donation.Among these we can identify the rational of natural motivations, as gaining an absence justifying the service, and motivations based on religious and humanitarian beliefs, pointing to the multitude of reasons related to the donation.These factors, however, appear more as additional factors than the main reason for the donation, the request or the request of an acquaintance.
Oh, there are multiple motivations, you have religious issues, there are people who donate for religious issues, there are people who donate to make a day of service, we cannot ignore it, because some of my friends donated because they earned a day of service.Because of this, I always donated and sometimes would work regularly.They donate because sometimes they need to, they have a loved one, because someone asked and also the person donates out of their own free will, therefore there are multiple reasons (E4 Potential).

Discussion
The statements of the participants in this survey point to a number of critical factors related to blood donation, which prevent, discourage and / or discourage potential donors and non-donors to participate in blood donation and remain active for future donations.
The absence and the asymmetry of information about the various stages of the blood donation process appear as the most critical factors in the process.If on the one hand information that would motivate people is not presented, in a more effective way, for donation blood, just as the importance and social value related to the act of donating, on the other hand, determining and highlighting the significance of this factor, sufficient information is not transmitted and in an appropriate manner about the criteria that enable a donor to donate.
The initial motivation for donation includes intrinsic aspects, such as altruism and the desire to help others, as well as social aspects, such as the experience of belonging to a group and the consequent desire to help people belonging to this group.Similarly, not giving, despite having intrinsic origin to the individual, such as fear and religious reasons, is stimulated by sociocultural variables 35,57 , reinforcing the findings of Oswalt 53 and Rezende et al. 54 .
The deficiency in the informational process, the main critical factor identified in this research, permeates all stages of the process, fueling increasing distrust of the system and, circularly, reactivating the lack of motivation for the donation.The lack of confidence in the system, among other attitudinal variables, was also identified in the study by Rezende et al. 54 and Andaleeb & Basu 55 .If, initially, there is a lack of advertisements and information relative to the recruitment of the donor, when in the process of screening this donor is blocked, a negative behavior is associated with the non-donation.Complementarily, this same subject tends to discredit the process, multiplying this opinion in relation to the group.
Consequently, the final evaluation of the process becomes negative.Adding to these facts, the absence of social value of the donor, which is only valued by the social group benefited from the donation, the friends and family members who requested the donation, makes the donor tend to distance himself from the donation process, not developing an awareness and behavior committed to social causes.
The stage of the screening, in this sense, is relevant to the maintenance of donors who are potentially attracted through campaigns, once they are adequately informed about the reasons for their rejection they may remain as donors for the future.And, in the case of capacity, information about the whole subsequent procedure will be used to qualify the perception of security and thus encourage new donors.
The social value of the donor must also be prioritized as a campaign.As Ludwig 56 points out, the ability to convert the donation experience into a value that is socially recognized can convert an anonymous donor into a source of social reference and the multiplication of the practice of donating.

Conclusions
Considering that in Brazil the blood donation rate is below the one recommended by OMS 2 , this study traces its importance to identify and analyze the critical factors of the blood donation process, explained through a sample of participants from Belo Horizonte, the capital of the state of Minas Gerais, one of the three largest cities in the country.
The results found point to the lack of information as the most critical factor in the blood donation process.This deficiency reflects the need for differentiated actions in social marketing for each step of the process.Recruiting donors, for example, should be developed differently, both in relation to the public, and in relation to the approach.Regarding the donors, the need to continue their behavior should be emphasized, facilitating the marking and the very process of collection.In relation to potential donors, it is necessary to mobilize through actions of reference groups, mainly those who have relatives and friends in a situation of need for blood donations.On the other hand, it is important to disclose and clarify the basic and necessary conditions required in order for donation to occur, which could be done through social networks, websites and informative blogs, preventing the potential unfit donor from reaching the collection center.
Among the results achieved, a relevant critical factor, is the dysfunction of the bureaucratic system of blood donation.Under the lens of participants, this can be viewed as a complicating factor in the stages of recruitment, awareness and registration of the blood cycle 44 , once the information provided officially by the system are understood insufficiently, incompletely and / or distorted by the receivers.
The survey results indicated stages of clinical and hematological screening as the most repulsive to potential donors, stressing that despite the awareness of the majority of participants of the importance of the steps in which the trials are held, low security awareness emerged as critical.
The results of this study point out, as initially proposed, the deterrent factors to the change the incremental or radical behavior proposed by social marketing 12 , thus setting a failure in the first stage of the behavioral change model proposed by Kotler and Armstrong 11 .This set of findings points to clear deficiencies in the entire blood donation process, analyzed, as proposed, from the perspective of social marketing, showing, in this way, the ineffectiveness of current policies and actions of blood donation.
For future studies it is suggested to apply the methodology adopted for this research in other Brazilian capital cities, as well as research of quantitative approaches about the critical factors of blood donation, in order to allow generalizations about this social phenomenon and identification of regional differences, demographic or even more comprehensive generational, in order to support public policies that are differentiated and adapted to different characterizations.

Chart 1 .
Description of the study subjects. ,714 is a weak issue of campaigns, advertisements.Generally, they tell you the surface, you get there one day, go there and cannot donate and you come home, then you think, I'm not going back to that place again... (E12 Donor).Liar [referring to the government campaigns].The person does not have the slightest notion of what they should have to donate, they say three or four things on television and when you get there to donate, you cannot donate.It is deceiving the citizens.It is lying to the citizen.That is absurd (E24 non donor).