Exploring women’s capability to donate blood in a Saudi blood bank: A COM-B model study

Abstract

Women contribute modestly to the blood supply in the Eastern Mediterranean region. The capability, opportunity, motivation-behavior model can be used to understand this phenomenon further. The framework suggests that capability, opportunity, and motivation are prerequisites for behavior. Most of the previously published research in Saudi Arabia has focused on motivation. This study aimed to evaluate the capability of donating blood among women who present to blood banks for donation and to compare the findings with those of men. A retrospective analysis of blood donor records was conducted to identify the outcomes of donor evaluation for women and men in a hospital blood bank over 13 months. Of 10,175 visits for whole blood donation, 9138 were by men and 1037 were by women. Donation was successful in 8641 visits by men (94%) and 616 visits by women (59%). In men, the most common cause of deferral was responses to the donor history questionnaire; in women, it was low hemoglobin. Compared with men, women were 12 times more likely to be deferred when presenting to donate blood. Logistic regression analysis revealed that women were less likely to be deferred for low hemoglobin levels as their age increased. The capability of women to donate blood is significantly lower than that of men, even if they are motivated and have opportunities. Anemia is the most common cause of deferral in women. Interventions are necessary to prevent, screen, and manage anemia in women in general and potential blood donors in particular.

1. Introduction

According to reports from the World Health Organization, the Eastern Mediterranean region is characterized by the lowest percentage of female blood donors (median 6%, range 0.4–31).^[1] To understand the reasons behind the low blood donation rates by women, we decided to view it according to the capability, opportunity, motivation-behavior model, which describes 3 prerequisites for any behavior: capability, opportunity, and motivation^[2] (Fig. 1). Studies performed in the region frequently used survey methodology, focused on investigating motivations, and occasionally inquired about opportunities, as viewed by women.^[3–5] However, evidence is scarce about the capability of women in the Saudi setting to donate blood when both motivation and opportunity are present. In the 8 studies from Saudi Arabia describing the causes of donor deferrals, the authors did not analyze women separately from men, or the number of women was very small, and the analysis was limited.^[6–13]

Figure 1.

The COM-B model for human behavior and its application to blood donation. COM-B = capability, opportunity, motivation-behavior.

Although it is common knowledge that low hemoglobin (Hb) is a common cause of deferral among women in Saudi Arabia, no studies from Saudi Arabia met the inclusion criteria for a 2019 systematic review and meta-analysis of low Hb deferrals, with only studies from the United Arab Emirates and Morocco being included from Arab countries.^[14]

An important reason for this scarcity in publications is the inaccuracy of the available data because of inaccurate documentation. These data inaccuracies stem from a gap between policies (work-as-prescribed) and practice (work-as-done) in the process of evaluating women presenting as potential blood donors, as illustrated in Figure 2. In many blood banks, policies (work-as-prescribed) dictate that the presenting donor is registered in blood bank records (electronically or manually), and then the donor is provided with the donor history questionnaire (DHQ), which the donor is expected to complete privately. This s followed by an interview with a blood bank employee to go over the answers and address any questions or concerns the donor might have. If the donor is found to meet the eligibility criteria, vital signs, weight, and Hb levels are measured in the physical examination step. Point-of-care testing is typically used to measure the Hb level. Donors who meet all the eligibility criteria are then allowed to donate.

Figure 2.

Blood donor processing steps, including work-as-prescribed, work-as-done, and a suggested workflow. DHQ = donor history questionnaire.

In settings where anemia is common among women, it is common practice for blood bank staff to prescreen women for anemia. A woman may be directed to get her Hb evaluated through point-of-care testing and then be registered in the blood bank records if the Hb is found to meet the donation eligibility criteria (work-as-done). This reduces the burden on the staff by not having to register an ineligible donor and saves the staff and presenting donor many minutes by skipping the DHQ. However, because the policies dictate that screening with DHQ must be performed before Hb measurement, and because many electronic information systems have forcing functions that require that registration of the potential donor is followed by DHQ screening, then Hb measurement, these women never get registered. This results in datasets of women deferred for low Hb values being inaccurate and sometimes nonexistent.

The objective of this study was to describe the differences in the outcomes of each step of donor evaluation according to gender in a hospital blood bank in Saudi Arabia. To address suspected data inaccuracies resulting from the gap between policies (work-as-prescribed) and practice (work-as-done), measures to capture missing data were introduced before data collection.

2. Materials and methods

2.1. Study duration and setting

This study was conducted at a hospital blood bank. Records of donor visits from August 1, 2023 to August 31, 2024 (13 months) were reviewed retrospectively.

Donor eligibility criteria followed the standards of the College of American Pathologists, the Association for Advancement of Blood and Biotherapies, and national standards. Hb levels were measured from a capillary blood sample using point-of-care testing. Men were accepted as blood donors if Hb was ≥13 g/dL, and women were accepted if Hb was ≥12.5 g/dL. The inter-donation interval for whole blood donation was 56 days for both genders.

2.2. Donor processing

After identifying the gap between work-as-prescribed and work-as-done and to ensure that the data of all women were captured, staff were retrained to register all donors electronically and follow the policies of donor assessment regardless of donor gender. If the staff deviated from the policy and measured Hb as an initial step of assessment for a female donor, the staff were provided with a paper form to capture the data of these women.

2.3. Collected data

The dataset included donor demographics (age and gender), weight, date of presentation, Hb level, deferral status, reason for deferral, and previous donation history. Donors were classified based on their success in donating, which was recorded as either a donation or no donation.

2.4. Ethical approval

The study was approved by the Unit of Biomedical Ethics, Faculty of Medicine, King Abdulaziz University (Reference no. 289-24).

2.5. Analytical sample

A convenience sampling method was employed. Participants were included in the study if they presented for blood donation at any time during the study period, resulting in 10,262 visits. Of these, 69 visits were related to apheresis platelet donation and were excluded, in addition to 17 individuals who did not continue with their registration and were excluded, and 1 individual was excluded because of being underage. This led to a final analytic sample of 10,175 visits. Figure 3 shows the details of the analyzed sample.

Figure 3.

Description of included donors who presented for blood donation at the study site over the study period of 13 mo. DHQ = donor history questionnaire.

2.6. Statistical analysis

Characteristics of the study participants were described using the mean for continuous variables and the proportion for categorical variables. Group differences were compared between women and men using the chi-square or Fisher’s exact test as appropriate for categorical variables and a 2-sample t-test for numerical variables.

The probability of success was calculated at different steps of the donation process. The odds ratio (OR) was calculated to quantify the odds of deferral among female donors relative to male donors, using a 2 × 2 contingency table based on their donation success. Finally, after univariate analysis to establish important factors predicting donation success in women, a multivariable logistic regression model was employed to examine the impact of factors such as age, nationality, and number of previous visits within the study period on successful donation (i.e., not being deferred). Statistical significance was set at P < .05. Data analysis was conducted using the STATA software.

3. Results

During the study period of 13 months, 10,175 visits were made to the blood bank for blood donation by 9138 men and 1037 women. Of these, 8113 were unique men and 898 were unique women, with 64.8% being Saudi and 35.2% non-Saudi. The donors’ characteristics and reasons for deferrals for males and females are summarized in Table 1 and Figure 3.

Table 1.

Characteristics of included donors.

	Gender
	Male	Female	Total	Test
N	9138 (89.8%)	1037 (10.2%)	10,175 (100.0%)
Age (mean [SD])	33.261 (9.763)	30.831 (10.698)	33.015 (9.888)	<0.001
Nationality
Saudi	5766 (63.1%)	825 (79.6%)	6591 (64.8%)	<0.001
Non-Saudi	3372 (36.9%)	212 (20.4%)	3584 (35.2%)
Reason for deferral
High hemoglobin	103 (20.7%)	1 (0.3%)	104 (12.2%)	<0.001
Low hemoglobin	12 (2.4%)	332 (94.1%)	344 (40.5%)
Abnormal vitals	12 (2.4%)	2 (0.6%)	14 (1.6%)
Underweight	0 (0.0%)	16 (4.5%)	16 (1.9%)
Failed DHQ	370 (74.4%)	2 (0.6%)	372 (43.8%)
Previous donation (mean [SD])	1.767 (4.623)	1.421 (3.227)	1.744 (4.544)	0.071
Donation success
No	497 (5.4%)	421 (40.6%)	918 (9.0%)	<0.001
Yes	8641 (94.6%)	616 (59.4%)	9257 (91.0%)
Visit count
1	8113 (88.8%)	898 (86.6%)	9011 (88.6%)	0.112
2	706 (7.7%)	108 (10.4%)	814 (8.0%)
3	214 (2.3%)	22 (2.1%)	236 (2.3%)
4	73 (0.8%)	7 (0.7%)	80 (0.8%)
5	25 (0.3%)	2 (0.2%)	27 (0.3%)
6	5 (0.1%)	0 (0.0%)	5 (0.0%)
7	2 (0.0%)	0 (0.0%)	2 (0.0%)

DHQ = donor history questionnaire, SD = standard deviation.

3.1. Women

Of the 1037 visits made by women presenting to the blood bank, 621 were registered through the information system, and 416 were captured through paper documentation. Among all these women’s visits, the donors’ mean age was 30.8 (18–66) years. A total of 331 unique women were first-time donors, and 176 were repeat donors. During the study period, 139 women had more than 1 visit.

Six hundred twenty-one visits went through the DHQ, and 2 women were deferred based on their responses to the DHQ. One woman was also deferred for high Hb, and 2 for abnormal vital signs. On the other hand, 416 visits were registered on paper only; of those, 349 were deferred (mostly due to low Hb in 332 visits), while 67 women had acceptable Hb but did not complete the registration and DHQ screening steps. The number of donations made by the women was 616. Thus, 59% of women who presented for donations had successful donations.

Among the deferred women, 332 (94%) were deferred for low Hb and had a mean age of 29.8. The Hb mean was 11.36 mg/dL (7–12.4). A multivariate logistic regression showed that for women, each additional year of age was associated with a 1.68% increase in the odds of having a successful donation, which was statistically significant (P = .008). Further analysis categorizing donors into age groups showed that women between the ages of 51 to 66 had better odds of successful donation than those between 16 to 35 and 36 to 50. Moreover, non-Saudi women had about 12.21% higher odds of successful donations than Saudi women. However, this result was not statistically significant (P = .48). Finally, women with 2 visits during the study period had 73.80% higher odds of successful donation than those with 1 visit; this was statistically significant (P = .014). Although it was not maintained as the number of visits increased beyond 2, the odds of success decreased but in a non-statistically significant relation. Table 2 presents the details of the regression analysis results.

Table 2.

Logistic regression to examine factors affecting a successful donation in females.

Donation success	Odds ratio	P value	95% CI
Age	1.02	.008	1.00–1.03
Nationality: (non-Saudi)	1.12	.482	0.81–1.55
Visit count:
(2)	1.74	.014	1.12–2.70
(3)	0.69	.386	0.29–1.61
(4)	0.29	.140	0.05–1.51
(5)	0.69	.799	0.04–11.26

CI = confidence interval.

3.2. Men

All 9138 visits by men were registered electronically. The mean age of the presenting men was 33.3 years (18–65). A total of 5036 were first-time donors, and 2648 were repeat donors. During the study period, 1025 had more than 1 visit.

All men’s visits went through the DHQ, with 370 (4%) being deferred based on their responses to it. Twelve men were deferred for low Hb, 103 for high Hb, 12 for abnormal vital signs, and none for being underweight. The total number of deferred men was 497, and the number of donations given by men was 8700. Of the men presenting for donation, 94.56% ended up with a successful donation procedure.

3.3. Comparison

Overall, 10% of the presenting potential donors were women; however, women contributed 7% of all donations. This is illustrated in Figure 4. The OR for women deferral compared to men was 9.85 (8.39–11.55), (P < .0001), indicating that women were almost 10 times more likely to experience deferral than their male counterparts. This calculation was performed after excluding 67 women who had adequate Hb levels but did not complete the registration and assessment processes.

Figure 4.

Donor presentation and eligibility: gender-based differences.

4. Discussion

The low number of women donors in Saudi Arabia could be attributed to a combination of health-related issues, psychological barriers, cultural norms, and physiological differences. Unlike many studies in Saudi Arabia that surveyed women to identify barriers to blood donation, we focused on women who presented for blood donation but were not able to donate blood.

Compared with other studies on patterns of blood donor deferral in Saudi Arabia, we recognized a gap in many blood banks between work-as-prescribed and work-as-done and attempted to address it. This understanding could only be achieved by spending time with frontline staff and cultivating a culture of psychological safety.^[15] Work-as-prescribed in the policies rely on the available functions in the information system used in the blood collection establishment. Many functions in such information systems are designed by individuals who have never participated in the tasks of blood donor registration and blood collection, with work-as-imagined by such information technology specialists being different from work-as-done. Realizing the differences between work-as-imagined, work-as-prescribed, and work-as-done led us to create a solution to capture missing data that were otherwise not captured. A key recommendation for information system designers is to provide the blood bank staff with flexibility, after electronic donor registration, to choose whether to initiate the assessment by DHQ and interview or by physical examination and Hb measurement (the suggested flow is illustrated in Fig. 2). This will allow the staff to direct women to physical examination and Hb measurement first to save valuable minutes from the staff and donor time if a low Hb deferral is required. Even in the case of male donors, having the flexibility to allow 2 tracks of work is likely to improve work efficiency and decrease waiting time.

Many women in our cohort were deferred for low Hb levels. A systematic review revealed that women are universally more likely to be deferred for low Hb levels than are men.^[14] This applied to all 64 analyzed studies, regardless of whether Hb thresholds to determine eligibility were similar for men and women, or whether lower thresholds were used for women. The ORs for low Hb deferrals were higher in India and Africa than in Europe. Our findings are consistent with these patterns and with the recognized high prevalence of anemia in Saudi Arabia among women of childbearing age. In a recent meta-analysis, the population prevalence of iron deficiency anemia in Saudi Arabia was estimated at 33.7%, and was most pronounced among pregnant women, women of childbearing age, children, and adolescents^[16] Iron deficiency without anemia is also extremely common among women, according to Owaidah et al^[17] Ferritin levels are overall lower in women than in men. In the setting of blood donors, and according to a study that assessed ferritin in successful blood donors from 4 Arab countries (including Saudi Arabia), mean ferritin for women who were giving their first blood donation was 49.1 ng/mL in comparison with 122 ng/mL in men giving their first donation.^[18]

Our data showed that older women were more likely to be able to donate blood than younger women. Studies conducted in other nations have reported similar results. In a study of deferral patterns among men and women in southwestern Spain, low Hb became less of a reason for deferral among women after the age of 50.^[19] In a systematic review, low Hb deferrals were also found to decrease in women aged more than 50 years.^[14] This was likely due to the cessation of monthly menstrual blood loss. This finding suggests that efforts targeting women to become or continue to be blood donors must focus on older age groups, rather than women below the age of 35 (such as university students).^[20] In our center, women above the age of 44 constituted only 7.8% of all women donors and 0.4% of all donors between 2005 and 2022.^[21] Recruiting and retaining more women in this age group will require targeted strategies that align with the characteristics of this specific group.

Our study revealed that 67 women who visited the blood bank had an adequate Hb concentration, but did not proceed with donation. We suspect that some of these women had the intention to return later to donate blood when their schedules allowed, but did not return. They might have been capable of donating blood but lacked the motivation or opportunity to donate blood on that day. Because our study’s primary goal was to evaluate the capability of women to donate blood if they had motivation and opportunity, these women were excluded from the calculations of successful donations.

Deferral of potential blood donors has a negative impact on their willingness to attempt blood donation in the future and affects blood availability and management of resources. However, we believe that reducing deferrals among women should make donor well-being the core principle. With increasing evidence of the negative impact of iron deficiency and iron deficiency anemia on the well-being of individuals and pregnancy outcomes, we advise against lowering Hb thresholds to reduce low Hb deferrals among women.^[22,23] Instead, we recommend considering nationwide initiatives for the prevention, screening, and management of iron deficiency and iron deficiency anemia.^[24,25] With improved access to care being one of the strategic goals of the Saudi Health Transformation Program of VISION 2030, means and resources will become available to provide such services to at risk groups. This will not only enhance the availability and well-being of potential blood donors, but might also improve physical, cognitive, and quality of life outcomes at the population level, and will prevent unnecessary use of donated blood for women with severe, poorly managed iron deficiency anemia presenting to emergency departments.

With blood donation being recognized as a cause of iron deficiency and iron deficiency anemia, further efforts are required to avoid blood donor harm. The optimal interval between blood donations must be scientifically identified for men and women in the Saudi setting, and whether ferritin should be utilized as an element in donor eligibility assessment should be further evaluated. The feasibility and benefits of oral or intravenous iron replacement for blood donors should also be investigated.

This study has several limitations. It primarily assesses donors’ capabilities in the pre-donation evaluation phase and does not address technical issues due to venous access problems that affect some donors. In addition, the data were collected from a single blood collection site over a limited period (13 months). It is, however, the first publication from Saudi Arabia that attempts to improve the accuracy of data describing women interested in donating blood, but unable to do so. Although the investigators cannot guarantee that all deferred women were captured manually or electronically, any unregistered visits would likely increase the observed difference between men and women regarding donation capability. Although the findings aligned with expectations, providing such evidence was crucial for addressing existing disparities.

Although this study sheds light on the capability aspect of the capability, opportunity, motivation-behavior model to explain the behavior of blood donation among women, further research is required to understand all prerequisites of blood donation from women in Saudi Arabia. This includes mixed-method research to understand the motivation for donating blood and how this may be affected by previous deferrals or previous adverse effects after blood donation. Opportunities must be further identified from the perspective of blood donors and blood collection sites with a high percentage of female donors.

In conclusion, while women made up 10% of the presenting donors in our center, they contributed 7% of the donated blood. Women were frequently deferred from blood donation, with only 59% being able to donate. Low Hb levels were the most common cause of deferral among the women. 94% of men were able to donate, and DHQ screening was the most common cause of deferral among them. To improve female donation rates, we recommend nationwide initiatives for the screening, prevention, and management of iron deficiency and iron deficiency anemia among high-risk groups, specifically women of childbearing age.

Author contributions

Conceptualization: Maha A. Badawi, Eman M. Mansory, Ahmed Al-malki, Sarah Adnan Abbas, Kholoud Gholam, Salwa I. Hindawi.

Data curation: Ahmed Al-malki, Sarah Adnan Abbas, Hassan Mutmi, Kholoud Gholam.

Formal analysis: Eman M. Mansory.

Methodology: Maha A. Badawi, Kholoud Gholam.

Project administration: Maha A. Badawi, Kholoud Gholam.

Supervision: Maha A. Badawi, Salwa I. Hindawi.

Validation: Eman M. Mansory.

Visualization: Eman M. Mansory.

Writing – original draft: Maha A. Badawi, Eman M. Mansory, Salwa I. Hindawi.

Writing – review & editing: Maha A. Badawi, Eman M. Mansory, Ahmed Al-malki, Sarah Adnan Abbas, Hassan Mutmi, Kholoud Gholam, Salwa I. Hindawi.