Attitude towards blood donation and its associated factors, types of blood donation, willingness, and feeling towards blood donation among potential blood donors in Ethiopia: systematic review and meta-analysis, observational study

ABSTRACT

Introduction

Blood donation is crucial for certain populations, such as pregnant mothers, anemic patients, traumatized patients, and individuals undergoing surgery. The imbalance between the number of blood donors and the demand for blood in Ethiopia is a serious public health concern. Having a favorable attitude towards blood donation could aid in correcting this imbalance. Therefore, this study aimed to assess the proportion of favorable attitudes, types of blood donation, willingness, and feelings towards blood donation in Ethiopia.

Methods

Several databases were searched to retrieve the available articles. Heterogeneity and publication bias were assessed using the Galbraith plot with Cochrane I² statistics and funnel plot with Egger's test, respectively. Subgroup analysis was done to identify the cause of the substantial heterogeneity.

Result

The pooled prevalence of favorable attitudes about blood donation was 65.28% (60.10–70.47). A higher prevalence was reported among studies conducted after 2020, in Northern Ethiopia and among health care professionals: 72.66%, 68.45%, and 69.41%, respectively. The percentages of people who had good feelings, willing to donate, and encouraged others to donate are 83.99%, 74.23%, and 77.96%, respectively. Conversely, 42.84% of participants believe that risk will happen following donation. There was an association between knowledge and attitude towards blood donation (AOR = 1.76; 95% CI: 1.48–2.99).

Conclusion

The findings of this study may imply the preparation of a blood donation campaign that helps the community. Concerned bodies from governmental and non-governmental organizations may arrange and design community education, which may increase the number of voluntary donors.

KEYWORDS:

• Blood donation
• attitude towards blood donation
• willingness
• blood donation type
• associated factors
• Ethiopia

Introduction

Donating blood is essential for a number of populations, such as pregnant mothers, anemic patients, traumatized patients, and individuals undergoing surgery [1]. A major public health concern is an imbalance between the number of blood donors and the demand for blood [2]. Having a favorable attitude on blood donation could aid in correcting this imbalance [3]. There is a significant scarcity of blood [4]. More than half of the blood was drawn from urban areas and high-income nations [5]. In the developed countries, most blood donors are voluntary and nonpaid. However, in low-income countries and rural residences, blood donors were donating only for their family members and friends [6]. Due to the increasing demand for voluntary blood donation, efforts to attract and retain donors should be strengthened in developing countries, particularly in Sub-Saharan Africa [7].

Numerous studies have been carried out all over the world to show the potential blood donors’ knowledge and attitudes toward blood donation. The majority of these studies demonstrated that people's knowledge and attitudes regarding blood donation are inadequate [8]. Inadequate knowledge, an unfavorable attitude, and negative feelings about blood donation were more prevalent in low-income nations like Ethiopia. However, depending on a person's personal characteristics, beliefs, motivational factors, education level, and other aspects, their understanding, feeling, willingness, knowledge, attitude, and practice regarding blood donation may vary [9]. The findings of additional studies attempted to pinpoint potential obstacles to voluntary blood donation. Low self-esteem, poor health status, and a lack of information about blood donation had an impact on potential blood donors attitude toward blood donation [10]. Thus, scholars recommended that the local and national blood banks should design a strategy to overcome the problems [11].

Ethiopia is a low-income nation where millions of people depend on safe blood products every day because of things like infectious diseases, vehicle accidents, malnutrition, civil wars, and restricted access to medical treatment. To ensure safe, adequate, and sustainable blood supplies throughout the nation, it is imperative to thoroughly examine and manage any potential barrios. In order to address the issue of high demand and restricted availability of blood, different single studies were conducted in Ethiopia. However, the issue of attitudes, feelings, and willingness to blood donation in the nation is not adequately addressed by the available data.

Therefore, to find new evidence supporting the research questions, this systematic review and meta-analysis focused on the topic of the study by looking for evidence on the attitude, willingness, type of blood donation, and feeling about blood donation. This review includes single studies that have not yet been reviewed, which gives novel evidence regarding the research questions. As a result, the findings of this systematic review and meta-analysis demonstrated the overall condition of national data about attitudes toward blood donation.

Method and materials

The study protocols

The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) reporting guidelines are used in this systematic review and meta-analysis to report the findings (Table S1) [12].

Databases and search strategy

All of the available articles which are required for the final analysis were found by searching many databases, including PubMed/MEDLINE, HINARI, EMBASE, Scopus, Google Scholar, African Journals Online (AJOL), and gray literature. All articles published without language restriction that report the potential blood donor's attitude and its associated factors, the types of blood donation, and the willingness and feelings of donors towards blood donation in Ethiopia were searched. Articles published until December 10, 2023, were included in the search. The last date for searching was December 15, 2023. The phrases ‘feeling,’ ‘willingness,’ ‘best blood donation type,’ ‘attitude toward blood donation,’ ‘associated factors,’ ‘determinant factors,’ ‘predictors,’ ‘incidence,’ ‘prevalence,’ and ‘Ethiopia’ were used to search the available articles. Boolean operators ‘AND’ and ‘OR’ were applied (Table S2).

Screening and eligibility of the studies

All retrieved articles were exported into the ‘EndNote reference software version 8 (Thomson Reuters, Stamford, CT, USA) citation manager’ to sort and remove possible duplications. Two authors independently reviewed and evaluated each study based on its relevance, title, and abstracts using predetermined inclusion criteria. After carefully examining the complete texts of the chosen articles, the three writers determined if the articles were eligible to be included in the final analysis. On the extraction sheet, the first author's name, study year, publication year, region where the studies were conducted, sample size, study population, method of data collection, potential blood donors’ attitude, feeling, willingness to donate blood, types of blood donation, and factors associated with attitude potential blood donors towards blood donation were extracted. Any disagreement that arose amongst the authors during the process was settled via conversation.

Inclusion and exclusion criteria

All studies conducted on the attitude of potential blood donors and its associated factors, the types of blood donation, donors’ willingness and feeling towards blood donation in Ethiopia, which were published until December 2023 were included. However, interventional studies, trials, systematic reviews, narrative reviews, qualitative studies, articles without full text, case reports, and policy statements were excluded from this systematic review and meta-analysis. Additionally, after evaluating each study's attributes using the NOS assessment, low-quality papers were removed from the final analysis.

Outcome measurement of the study

This systematic review and meta-analysis had four main outcomes. The first outcome is the attitude of potential blood donors towards blood donation, which is measured as a favorable attitude or unfavorable attitude. The second outcome variable is the types of blood donation, which are volunteer type of blood donation, replacement type of blood donation, and paid type of blood donation. The third outcome variable is the donor’s willingness to donate blood in the future (willing or not willing). The last outcome is the donor's general feeling about blood donation. This was measured as a good feeling, not a good feeling, and neutral.

Quality assessment

Two authors separately extract the findings on the extraction sheet, and a third author verifies it, in order to ensure the study's quality. The Newcastle Ottawa Scale (NOS) was utilized to evaluate the attributes of every study [13]. The main evaluation criteria used to determine the quality of the studies were the sample's representativeness, the study's methodological quality, the study's comparability, the measurement of exposure or risks, the evaluation of the study's outcome, and statistical testing. Studies that had a score of at least seven out of ten were deemed to be of excellent quality and were incorporated into the final analysis. Each author independently assesses the search output prior to reconciliation as a team, and finally, the authors reach consensus.

Data processing and analysis

This systematic review and meta-analysis pooled data using a weighted inverse variance random-effects model at 95% CI to examine the overall pooled prevalence of favorable attitudes of potential blood donors and factors associated with it, the percentage of voluntary, replacement, and paid types of blood donors, the donors’ feelings, and the willingness to donate blood in the future [14]. Spreadsheets made in Microsoft Excel were used to extract and clean the data before they were exported to STATA/MP 17.0 for analysis. The Cochrane Q test, the I² with its related p-value, and the Galbraith plot were used to evaluate the studies’ heterogeneity [15]. Subgroup analysis was carried out by study year, region, study population, data collection method, and sample size in order to investigate the cause of heterogeneity. In addition, sensitivity analysis was performed to look at the possibility of an influential study. Furthermore, a funnel plot and Egger's test were used to assess the possibility of publication bias [16]. A log odds ratio was employed to ascertain the association between the level of attitude and associated factors about blood donation. Ultimately, a statistical test was deemed statistically significant if its P-value was less than 0.05.

Result

In this study, 120,432 articles were retrieved from different databases (Figure 1).

Figure 1. Flow chart of selection for systematic review and meta-analysis on the attitude and its associated factors, the types of blood donation, willingness, and feeling towards blood donation among potential blood donors in Ethiopia.

Characteristics of the studies and study participants

In this study, 38 single articles with a total of 16,196 study participants were included. The studies were conducted in different regions of Ethiopia until December 2023. Of these studies, fifteen were carried out in Central region of Ethiopia [4,17–30], fifteen were carried in Northern Ethiopia [31–45], and the seven were done in Southern Ethiopia [11,46–51]. The sample size was ranged from 15 to 845. The design of all articles is cross-sectional (Table 1).

Table 1. Characteristics of included studies for systematic review and meta-analysis on the attitude and its associated factors, the types of blood donation, willingness and feeling towards blood donation among potential blood donors in Ethiopia.

Author	Study area	Sample size	Favorable attitude (%)	Best blood donation type (%)				Willingness (%)		General feeling (%)
				Volunteer	Replacement	Paid	Don’t know	Yes	No	Good	Bad	Neutral
Abdulhakim etal, 2023	Southern	422	49.5	97.2	1.7	0.9	0.2	85.1	14.9	62.6	3.8	15.2
Abiot Aschale etal, 2021	Central	595	85.0							80.3	2.2	6.2
Nigatu A etal, 2014	Central	399	47.4	96.0		4.0
Addisu AG etal, 2017	Southern	376	45.2	38.0	17.6	39.1	5.3	52.7	47.3	88.8	5.3	5.9
Ahmed Seid etal, 2022	Central	601	58.9
Nigussie Yirgu etal, 2021	Central	122	67.2	83.6	4.1	0.8	11.5	82.8	17.2	66.4	4.9	19.7
Ayenew BA etal, 2020	Central	334	69.2	35.3	57.5	3.6	3.6
Kebede A etal, 2022	Northern	342	66.7	48.5	17.5	19.6	14.3
Enawgaw etal, 2019	Northern	401	94.5	42.9	57.1	0.0	0.0
Misganaw etal, 2014	Central	384	68.0
Malako etal, 2020	Southern	218	58.7	57.8	32.6	0.9	8.7	56.4	43.6	99.1	0.0	0.9
Terefe E etal, 2018	Northern	15	86.7	73.3	26.7	0.0	0.0	100.0	0.0	86.7	0.0	13.3
Mirutse etal, 2014	Northern	735	70.9
Mijena etal, 2019	Central	383	61.1
Arage etal, 2017	Northern	427	48.9
Beyene etal, 2020	Central	410	48.0	16.1	53.2	21.5	9.3	39.8	60.2	48.5	5.6	45.9
Gebresilase etal, 2017	Central	360	41.1
Darega B etal, 2015	Central	609	61.6	13.0	4.1	0.2	1.1	63.9	27.4
Mulatu K etal, 2017	Southern	250	88.8	67.6	28.8	3.6
Kedir Urgesa et al, 2017	Central	845	32.9	87.7	3.2	1.1	8.0			94.4	1.8	3.8
Melku M et al, 2018	Northern	255	79.2	91.8	5.5	0.0	2.7	85.5	6.7	86.3	10.2	3.5
Yosef T et al, 2021	Southern	394	58.1
Seid T etal, 2017	Northern	237	63.3
Tadesse W etal, 2018	Northern	339	65.8	92.3	0.0	31.9		82.9		93.5	0.0	0.0
Tadesse et al, 2018	Northern	556	43.7
Melku M et al, 2016	Northern	768	82.0	46.4	78.0	6.4		79.2		96.5	3.5
Dejene M etal, 2021	Northern	412	67.2
Gelaw, et al, 2022	Northern	830	83.5	79.4	0.0	17.5		79.8		92.8	1.8	4.9
Jemberu et al, 2016	Northern	772	52.2	74.0	3.2	0.3	0.0	77.5
Nigussie etal, 2020	Central	383	61.1					77.0	23.0
Ayenew Kassie etal, 2020	Northern	515	39.8							65.8	13.6	0.0
Jibril et al, 2020	Central	407	78.1	94.3	4.4	1.0	0.2	0.0	0.0	99.0	0.2	0.7
Shama et al, 2022	Central	360	78.9	58.3	14.4	1.7	25.6	76.1	23.889	90.3	1.9	7.8
Kebede Z, et al, 2021	Central	349	61.9					96.56	3.4384
Ermias R etal, 2019	Southern	650	77.4	27.5	5.1	3.4		84.46	15.538	87.2	4.0	8.8
Tebabal et al, 2023	Northern	491	85.3	71.3	0.0	0.0
Derartu Y etal, 2021	Southern	250	90.4

Prevalence of favorable attitude towards blood donation

The overall pooled prevalence of favorable attitudes toward blood donation among potential blood donors in Ethiopia was 65.28% (95% CI: 60.10-70.47) (Figure 2).

Figure 2. Frost plot on the pooled prevalence of favorable attitude towards blood donation among the potential blood donors in Ethiopia

Publication bias

The asymmetrical distribution of the included articles was visible in the funnel plot, and Egger's test revealed a statistically significant result (p = 0.003), indicating the possibility of publication bias (Figure 3).

Figure 3. Funnel plot with 95% confidence limits on the attitude and its associated factors, the types of blood donation, willingness, and feeling towards blood donation among potential blood donors in Ethiopia.

Heterogeneity

Visual examination of the Galbraith plot reveals significant variation among the studies (I² 98.37%, p < 0.001) (Figure 4)

Figure 4. Galbraith plot on the attitude and its associated factors, the types of blood donation, willingness, and feeling towards blood donation among potential blood donors in Ethiopia.

Sub-group analysis

Sub-group analysis was performed using study year, region where the studies were done, study population, method of data collection, and sample size to identify the cause of high heterogeneity. Research articles conducted after 2020 had the highest pooled prevalence of favorable attitudes toward blood donation: 72.66 (95% CI: 62.73, 82.60). Similarly, research conducted in Northern Ethiopia revealed the highest percentage of favorable attitudes regarding blood donation: 68.45 (95% CI: 59.95, 76.96). Furthermore, research on healthcare workers revealed the highest proportion of favorable attitudes toward blood donation: 69.41 (95% CI: 61.11, 77.71) (Table 2).

Table 2. Sub-group analysis on the pooled prevalence of favorable attitude towards blood donation among potential blood donors in Ethiopia.

Valuables	Classifications	Studies	Prevalence (95%CI)	I^2 (%)	P-value
Study year category	Before 2020	29	63.24 (57.35,69.13)	98.33	<0.001
	After 2020	8	72.66 (62.73,82.60)	98.05	<0.001
Region	Northern Ethiopia	15	68.45 (59.95,76.96)	98.71	<0.001
	Southern Ethiopia	7	66.96 (53.21,80.71)	98.58	<0.001
	Central Ethiopia	15	61.37 (54.52,68.23)	97.55	<0.001
Study population	Health care professionals	9	69.41 (61.11,77.71)	97.07	<0.001
	All students	12	64.06 (52.93,75.19)	99.26	<0.001
	All adults in the community	4	60.77 (58.29,63.24)	0.00	<0.001
	Civil servants	6	63.25 (53.06,73.45)	96.22	<0.001
	Health science students	6	65.13 (49.80,80.45)	98.64	<0.001
Method of data collection	Face to face interview	13	64.06 (52.93,75.19)	99.26	<0.001
	Self-administered	24	65.72 (60.53,70.92)	97.03	<0.001
Sample size	<400	19	66.00 (59.79,72.21)	96.48	<0.001
	>400	18	64.33 (56.24,72.41)	99.05	<0.001

Sensitivity analysis

In this systematic review and meta-analysis, a leave one-point sensitivity analysis conducted using the random-effects model revealed that all of the points were estimates within the overall 95% confidence interval (60.10–70.47), indicating the absence of any influential study (Table S3).

Types of blood donation

The overall pooled proportion of volunteer blood donors in Ethiopia is 63.25 (95% CI:50.96,75.54) (Figure 5)

Figure 5. Frost plot on volunteer blood donation among the potential blood doners in Ethiopia

Feeling, willingness, and encouragement of blood donation

Of all study participants, only 49.44 (26.79, 72.09) knew their blood group. The proportion of good feeling about blood donation is 83.99 (95% CI: 79.39, 88.59). The pooled proportion of participants who were willing to donate blood in the future is 74.23 (95% CI: 67.78, 80.69). Similarly, 77.96 (95% CI: 69.32, 86.60) of study participants encouraged others to donate blood. In contrast, 42.84 (95% CI: 32.91, 52.76) of participants think that risk will happen after blood donation (Table 3).

Table 3. The feeling, willingness, and encouragement of others to donate blood among potential blood donors in Ethiopia.

Valuables	Classifications	Studies	Prevalence (95%CI)	I^2 (%)	P-value
Know their own blood group	Yes	9	49.44 (26.79,72.09)	99.7	<0.001
Best blood donation type	Volunteer	21	63.25 (50.96,75.54)	99.7	<0.001
	Replacement	17	22.84 (14.81,30.88)	99.5	<0.001
	Paid	17	07.24 (05.60,08.87)	97.9	<0.001
	Don’t know	10	06.66 (04.70,08.62)	96.6	<0.001
Do you think any risk happen after blood donation?	Yes	10	42.84 (32.91,52.76)	98.0	<0.001
	No	10	32.04 (16.25,47.84)	99.9	<0.001
	Don’t know	6	16.68 (05.43,27.94)	98.9	<0.001
Do you encourage others to donate blood?	Yes	10	77.96 (69.32,86.60)	98.9	<0.001
	No	8	23.15 (12.55,33.75)	99.1	<0.001
Willingness to donate blood in the future	Yes	16	74.23 (67.78,80.69)	98.2	<0.001
	No	12	25.57 (17.12,34.02)	98.6	<0.001
What is your feeling about blood donation?	Good	17	83.99 (79.39,88.59)	86.1	<0.001
	Not good	13	04.09 (02.75, 05.44)	92.7	<0.001
	Neutral	13	09.71 (06.36,13.70)	97.4	<0.001

Factors associated with attitude towards Blood Donation in Ethiopia

The knowledge of potential blood donors about blood donation was significantly associated with the attitude of blood donors. Thus, study participants who had good knowledge about blood donation were 1.76 times more likely to have a favorable attitude towards blood donation than their counterparts (AOR = 1.76; 95% CI: 1.48-2.09) (Figure 6).

Figure 6. The overall pooled odds ratio of the association between the knowledge and attitude of potential blood donors towards blood donation in Ethiopia

Discussion

According to this study, among potential blood donors in Ethiopia, the total pooled prevalence of a favorable attitude toward blood donation was 65.28% (95% CI: 60.10–70.47). This is lower than studies from the Kingdom of Saudi Arabia (99%) [52], Nigeria (81.6%) [53], Iran (98%) [54], and Saudi Arabia (78.6%) [55]. This disparity may result from the different study settings; the current study is being conducted in a low-income nation where the majority of the study participants do not have access to the media or other sources of information regarding blood donation. In addition, the results of the current study showed a pooled prevalence, whereas the previous studies were results of single studies. Furthermore, in the previous studies, the study populations were exclusively health care workers and students, whereas the populations in the current study were all potential blood donors in the country, which may decrease the pooled effect.

The pooled prevalence of favorable attitudes towards blood donation varies depending on the study year, study population, data collection method, and study areas, according to subgroup analysis. Research articles conducted after 2020 have a greater pooled prevalence of favorable attitudes towards blood donation than research articles conducted before 2020. This is because, year after year, improvements in technology, the availability of media that disseminates information, access to contemporary education, and public awareness of blood donation may increase the level of favorable attitude towards blood donation. In addition, there are different campaigns that advertise the benefits of blood donation [56,57]. This study also demonstrated that studies conducted in Northern Ethiopia had a higher pooled prevalence of favorable attitudes regarding blood donation than studies conducted in Central and Southern Ethiopia. This could be because the majority of people in central and southern Ethiopia lead pastoral lifestyles, which could lower their degree of formal schooling. Similarly, studies conducted among health care workers exhibit a more positive attitude than other research participants. This is because health care professionals are aware of the general advantages of blood donation for the general public. In terms of data collection methodology, research employing the self-administered technique reports a higher proportion of favorable attitudes toward blood donation than research employing face-to-face interviews. This may be due to the fact that participants who were assessed using the self-administered data collection method have a social desirability bias.

In this study, 49.44 (26.79, 72.09) of the study participants knew their blood type. This small number could be the result of poor awareness and access [58]. The proportion of good feeling of participants about blood donation accounting for 83.99% (79.39, 88.59), which indicates the majority of participants clearly understood the benefit of blood donation [59]. Moreover, 42.84% (32.91, 52.76) of research participants believe that donors will be at risk following a blood donation. This is due to the possibility that some segments of the public are unaware of the advantages that blood donation has on the receivers.

The level of knowledge about blood donation was associated with a favorable attitude toward blood donation among potential blood donors in Ethiopia. Accordingly, having good knowledge about blood donation was 2.85 times more likely to have a favorable attitude towards blood donation than having poor knowledge. This finding is supported by studies done in developing countries [60], South India [61], Greek [62], Saudi Arabia [36,63], North India [39], and Pakistan [40]. This could be because people who have good knowledge about blood donation understand how blood is vital to save the lives of millions, particularly those of pregnant mothers, anemic patients, trauma survivors, patients undergoing major surgery, cancer patients, and others.

Strength and limitation of the study

➢	This study covers a wide area and investigates different articles, making the review more accurate and provide high quality result.
➢	Subgroup and sensitivity analyses were carried out to investigate the heterogeneity of the included studies.
➢	The results of this study are limited to Ethiopia, which is not generalizable for the other world. Ethiopia.
➢	Studies whose study design cross-sectional were limit investigation of the cause – effect relationship

Conclusion

The findings of this study may imply the preparation of a blood donation campaign that helps the community. Concerned bodies from governmental and non-governmental organizations may arrange and design community education, which may increase the number of voluntary donors.

Author’s contributions

AG and MB designed the study, designed and run the literature search. All authors (AG, MB, and AW) acquired data, screened records, extracted data, and assessed the risk of bias. AG did the statistical analyses and wrote the report. All authors provided critical conceptual input, analyzed and interpreted the data, and critically revised the report. All authors read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

All related data have been presented within the manuscript. The dataset supporting the conclusions of this article is available from the authors on request.