Regena Spratling Facilitators and Barriers to Minority Blood Donations A Systematic Review Regena Spratling

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Facilitators and Barriers to Minority
Blood Donations
A Systematic Review
Regena Spratling ▼ Raymona H. Lawrence
Background: Minority blood donations have historically been low in the United States; however, increasing the proportion of
minority blood donations is essential to reducing blood transfusion complications—particularly in African Americans with sickle
cell disease and thalassemia.
Objectives: The research question was as follows: What are the facilitators and barriers to blood donation in minority populations?
Methods: Beginning August 2017, we conducted a literature search using the following electronic databases: CINAHL Plus with
Full Text, Academic Search Complete, MEDLINE, PsycINFO, Sociological Collection, Cochrane Library, ProQuest Dissertation
and Theses, and PubMed, which continued through December 2017. Based on primarily descriptive data in the articles
(n = 15), the systematic review proceeded as a meta-synthesis. An inductive approach was used to analyze commonalities,
differences, patterns, and themes in the study findings; interpret the findings; and synthesize the findings to generate new
knowledge about the phenomena of study.
Results: The themes included (a) knowing a blood recipient; (b) identifying with culture, race/ethnicity, and religious affiliation;
and (c) medical mistrust and misunderstanding. All were prominent in the descriptions of minorities on blood donation and exist
as facilitators and barriers.
Discussion: The reviewed studies demonstrated that facilitators and barriers to minority blood donations are complex and exist
concurrently. Community education and communication about blood donation have a positive effect on fellow community
members, including friends and family, in racial and ethnic minorities that are underrepresented among blood donors. Findings
further suggest the need to rebuild trust among minority communities.
Key Words: blood donors  minority groups  qualitative research  systematic review
Nursing Research, May/June 2019, Vol 68, No 3, 218–226
Minority blood donations have historically been low
in the United States (Yazer et al., 2017). Increasing
the proportion of minority blood donations is
essential to reducing blood transfusion complications, par-
ticularly in individuals with sickle cell disease (SCD) and
thalassemia, for several reasons (Yazer et al., 2017). First, SCD
and thalassemia disproportionately affect minority racial and
ethnic populations in the United States. For example, SCD
occurs in about 1 in every 500 African American (AA) births,
1 in every 36,000 Hispanic-American births, and 1 in every
100,000 Caucasian births (Hassell, 2010). Thalassemia is
prevalent in populations with roots in the Mediterranean,
Middle East, Indian subcontinent, Southeast Asia, and China
(Li, 2017). Second, blood from donors—with similar backgrounds
as the recipients—is more likely to be a close match (Frye
et al., 2014). Unmatched blood can cause potentially severe
transfusion complications. Therefore, there is a critical need
for blood donations from minorities to improve transfusion
outcomes in minority populations.
Individuals with hemoglobin disorders often need
transfusions—sometimes chronically and sometimes inter-
mittently. If exposed to unmatched donor blood, the risk is
alloimmunization: the development of antibodies to the for-
eign red blood cell antigens (Charbonneau & Daigneault,
2016). Increasing blood donations among minorities can
ensure better access to minor antigen-matched units; how-
ever, strategies for promoting donation in these popula-
tions require awareness of the unique characteristics of
minority groups and blood donation, as well as programs
that address facilitators and barriers to minority blood dona-
tion (Charbonneau & Daigneault, 2016; Frye et al., 2014). The
Regena Spratling, PhD, RN, APRN, CPNP, is Associate Professor and Associate
Dean & Chief Academic Officer for Nursing, Georgia State University, School
of Nursing, Byrdine F. Lewis College of Nursing & Health Professions, Atlanta.
Raymona H. Lawrence, DrPH, MPH, MCHES, is Associate Professor, Georgia
Southern University, Jiann Ping Hsu College of Public Health, Community
Health Behavior and Education, Statesboro.
This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-
NC-ND), where it is permissible to download and share the work provided it
is properly cited. The work cannot be changed in any way or used commer-
cially without permission from the journal.
Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc.
DOI: 10.1097/NNR.0000000000000355
218 www.nursingresearchonline.com Nursing Research • May/June 2019 • Volume 68 • No. 3

goals of this systematic review are to expand the knowledge of
facilitators and barriers to minority blood donation and to
recommend strategies that will increase blood donations
within minority communities.
Blood transfusions increase hemoglobin levels, increase
blood flow, improve oxygen delivery to the tissues, and dilute
the abnormal red blood cells containing sickled hemoglobin,
thus increasing the number of circulating normal red blood
cells (Estcourt, Fortin, Hopewell, Trivella, & Wang, 2017). Phe-
notypic incompatibility in blood transfusions results in the de-
velopment of antibodies over time that attack red blood cells,
making subsequent transfusions less effective and increasing the
risk of transfusion complications (Charbonneau & Daigneault,
2016). These antibodies to antigens, if present in subsequently
transfused blood, will trigger a dangerous hemolytic transfusion
reaction when transfused red blood cells are destroyed by the
immune system (Estcourt et al., 2017).
Minority blood donors are essential for a diverse supply
of blood because they provide greater access to corre-
sponding phenotypes, often rare ones, required for individ-
uals with diseases such as SCD and thalassemia. However,
minorities are historically underrepresented among blood
donors. In the United States, an estimated 11% to 21% of blood
donations are from minority populations based on the National
Blood Collection & Utilization Survey 2011 (U.S. Department
of Health and Human Services, 2011). More recent surveys
from eight blood centers in 17 states noted decreasing blood
donations overall and a continued underrepresentation of mi-
nority donors. For example, Black or AA donors constituted
approximately 5% of all donors from 2006 to 2015 (Yazer
et al., 2017). A decreased proportion of minority blood donors
has also been reported in Canada (Charbonneau & Daigneault,
2016) and France (Grassineau et al., 2007).
Increasing minority blood donations is a complex public
health issue with several barriers to minority blood donations.
Minorities have reported higher deferral rates and lack of
awareness about the process of blood donation (Frye et al.,
2014). Less than 1% of all donors experience events such as
fainting and fatigue (U.S. Department of Health and Human
Services, 2011); however, despite a relatively low occurrence
of adverse events, fear of these events is a commonly reported
barrier to blood donation among minority populations (Shaz,
Demmons, Hillyer, Jones, & Hillyer, 2009). Barriers to blood
donation also include deferment due to low hemoglobin,
consisting of almost half (48%) of all deferrals from all poten-
tial donors in the United States (U.S. Department of Health
and Human Services, 2011). Mobile blood drives remain the
major source (66%) of blood collections in the United States
(U.S. Department of Health and Human Services, 2011). These
blood drives often recruit minority populations in the commu-
nity, at local churches, and other gatherings, yet a substantial
or sustainable increase in donations from these blood drives
has not been found (Yazer et al., 2017).
The current knowledge on facilitators and barriers to mi-
nority blood donations is limited. Systematic reviews on blood
donations and blood donors exist, although none address
blood donation issues specific to minorities and none review
the race/ethnicity of study samples (Bagot, Murray, & Masser,
2016; Bednall, Bove, Cheetham, & Murray, 2013; Godin, Vézina-
Im, Bélanger-Gravel, & Amireault, 2012). In addition, Bednall
et al. (2013) reviewed blood donation behavior and intentions
and cited the need for research with minorities as they often re-
port additional barriers to blood donation. The purposes of this
systematic review are to examine the facilitators and barriers to
minority blood donations and recommend strategies to increase
donations in the community. Therefore, the following research
question was asked: What are the facilitators and barriers to
blood donation in minority populations?
METHODS
Search Strategy
Prior to beginning the systematic review, the principal investi-
gator (PI) conducted a preliminary search to ensure the ab-
sence of similar reviews and gain understanding of existing
literature on minority blood donations. We consulted experts
on systematic review and meta-analyses: a librarian with exper-
tise in nursing and health literature and experts on minority
blood donation and blood transfusion complications associ-
ated with the hemoglobinopathies of SCD and thalassemia,
on search approach and terminology and goals of the review.
The systematic review proceeded using Preferred Reporting
Items for Systematic Reviews and Meta-Analyses, and the re-
search question served as basis for identification, selection,
and appraisal of studies and collection and analysis of data from
reviewed studies (Moher, Liberati, Tetzlaff, & Altman, 2009).
The literature search began in August 2017 using the elec-
tronic databases CINAHL Plus With Full Text, Academic Search
Complete, MEDLINE, PsycINFO, Sociological Collection,
Cochrane Library, ProQuest Dissertation and Theses, and
PubMed. Search alerts were also initiated for databases that
continued the search through December 2017. There were
no restrictions on publication year, publication type, or article
type. The keywords used in the search included combinations
of the following words: blood donation, blood donor, minor-
ity, AA, Black, race and ethnicity, and Hispanic or Latino.
The search databases and search combinations are presented
in Table 1.
Inclusion and Exclusion Criteria
Inclusion criteria were (a) data-based studies that sampled mi-
nority blood donors and minority blood donations or included
minorities in description of blood donor samples; (b) data from
minority participants on process of blood donation; and (c)
English language. Exclusion criteria were (a) data-based studies
Nursing Research • May/June 2019 • Volume 68 • No. 3 Minority Blood Donations 219

on blood donation using blood center or national survey data
and (b) methodological and theoretical studies. In addition,
in multiple data-based reports of a single study sample, only
one sample was reported with data from each study analyzed.
The title and abstract of each article in the search pool
(n = 1,352) were carefully reviewed by the PI. Initial review fo-
cused on removal of duplicate articles and exclusion of articles
obviously not relevant to search terms (e.g., animal studies,
etc.). The resulting pool (n = 545) was further refined by ex-
cluding articles that focused on viral and bacterial infections,
genetic components of bloods, and risk for alloimmunization.
Articles originating from countries outside of the United States
were retained as long as the abstracts were in English. Detailed
review of abstracts excluded summary reports, historical re-
views, literature reviews, editorials, periodicals, or news briefs
and articles that were not data based.
The remaining 42 full-text articles were reviewed in their
entirety. Of the articles reviewed, 18 articles contained demo-
graphic data from blood centers or “blood banks” and national
surveys. Some articles reported data from blood centers re-
garding the effectiveness of an intervention or program; how-
ever, the data were not linked to participants (e.g., an increase
in blood donations in a blood center was attributed to a pro-
gram without data to indicate that donors were engaged or
participated in program). We excluded articles that focused
on blood centers without data from minority blood donors
on donations.
Of the 24 remaining articles, 5 were qualitative studies, 2
were mixed methods, and 17 were quantitative descriptive.
Eight of the quantitative descriptive articles included qualita-
tive data and descriptions from participants, while 9 contained
quantitative data only. Statistical methods are relevant to a
meta-analysis to integrate the results of studies—particularly
intervention studies (Moher et al., 2009). Based on the pri-
marily descriptive data from the articles and the lack of interven-
tion studies, the systematic review proceeded as a descriptive
meta-synthesis (Finfgeld, 2003), focusing on the facilitators
and barriers to blood donation in minority populations with
15 articles.
Meta-synthesis is the qualitative aggregation and interpre-
tation of descriptive findings that have been abstracted from
study findings (Finfgeld-Connett, 2010). Similar to a meta-
analysis, a meta-synthesis includes a purpose, research ques-
tion, inclusion criteria, study and sample characteristics,
and qualitative data collection and data analysis techniques
(Sherwood, 1999). A meta-synthesis examines a broad phe-
nomenon (Finfgeld, 2003), such as facilitators and barriers
to blood donations in minority populations.
Data Abstraction
Data were abstracted from 15 articles in the following cate-
gories: study design and data analysis methods, sample size,
participant race/ethnicity and gender, donor type (nondonor
or experienced donor), geographic location (United States
or other country), and community location (e.g., community,
church, college, etc.). Narratives from participants, themes,
and strategies presented were abstracted from the findings, dis-
cussions, and conclusions.
Data Analysis
An inductive approach was used to analyze commonalities, dif-
ferences, patterns, and themes in study findings; interpret the
findings; and synthesize the findings to generate new knowledge
about the phenomena of study (Finfgeld, 2003; Paterson, 2001).
The findings were categorized and later collapsed into themes
(Finfgeld-Connett, 2010). The steps of the thematic analysis in-
cluded (a) translating the findings of each study into themes,
(b) comparing and contrasting the themes by identifying sim-
ilarities and differences among themes, and (c) determining
the key themes and hypothesizing how themes relate to each
other (Paterson, 2001).
In the analysis, each study was reviewed by the PI, and
themes were validated by the PI and the research team with
a total of three members (Paterson, 2001). The research team
had expertise with minority blood donations, minority popu-
lations with SCD and thalassemia, research with minorities,
and qualitative methods. Sampling and data analysis decisions
were recorded in field notes and an audit trail, and consensus
on decisions was achieved among the research team (Finfgeld-
Connett, 2010; Paterson, 2001).
RESULTS
Study Selection
The initial search yielded 1,352 articles. After eliminating dupli-
cates and nonrelevant articles (n = 807), excluding articles by
abstract (n = 503), and excluding articles by full text (n = 26),
15 articles were included in this systematic review (See Figure 1).
TABLE 1. Search Strategy
Database Search Terms Articles
CINAHL Plus with Full Text, Academic Search
Complete, MEDLINE, PsycINFO, Sociological
Collection
Blood donation OR Blood donor AND Minority groups
OR African American OR Black OR (Race and
ethnicity) OR (Hispanic or Latino)
n = 718
Cochrane Library, Proquest Dissertation and
Theses, PubMed
Blood donation OR blood donor AND minority OR
African-American OR race
n = 634
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