CURRENT PERCEIVED RISKS OF TRANSFUSION IN THE UK AND RELEVANCE TO THE FUTURE ACCEPTANCE OF BLOOD SUBSTITUTES

Abstract

Data has been gathered on the perception of risk associated with blood donation and transfusion (including the use of so-called blood substitutes) by UK general practitioners (GPs), anaesthetists, healthcare journalists and blood donors of both genders. A questionnaire survey was conducted from March – July 2000 involving (i) GPs (n = 88), (ii) anaesthetists (n = 143), (iii) journalists (n = 20), and (iv) blood donors (n = 250). Respondents rated (scale of 1–7) the general risk of blood transfusion and the risk of infection associated with blood transfusion and donation. Respondents were asked through free response questions to identify the risks they most associated with blood transfusion and the infections associated with blood transfusion and donation. They were also asked to indicate their preference for their own blood, compared to donor blood or a blood substitute and to make a choice between donated blood or a blood substitute. The percentage of respondents who preferred to receive their own blood, compared to donor blood or a suitable substitute, was 73–94%. When required to choose between donor blood or a blood substitute, there were significant (P < 0.05) differences between sample groups: anaesthetists and GPs preferred to receive a blood substitute (52–59%), whereas blood donors and journalists preferred donated blood (74–93%). These findings have clear implications for the future development and implementation of modern transfusion options, including the use and acceptability of blood substitutes as alternatives to donor blood.

INTRODUCTION

While the biology of blood and its products is becoming increasingly better understood and the spectrum of transfusion options increasing, it is surprising to note how little research has been conducted into the public' perceptions of risk with regard to the receipt of blood and blood products [1-4]. This lack of research contrasts markedly with many other technological advances and developments, where information on the public' perceptions of risk and how this influences behaviour has been both sought and gained. Presently, only limited information is available on how different key groups in society perceive the risk(s) associated with blood transfusion [[5]]. However, this is clearly a key and timely issue given the recent backlash against genetically-modified foods [[6]], for example.

At the present time, little is known about the public perception of risk associated with blood transfusion, despite the fact that, in the UK for example, the National Blood Service currently directs enormous effort and resources towards making transfusion as safe as possible. The notion of ‘acceptable risk’ has long been a key question in risk research [[7]]. Given that zero risk for transfusion is an unachievable goal, the question now becomes ‘how safe is safe enough’? This question is currently very difficult to answer given the lack of knowledge regarding people' perception of risk for transfusion. The first step in such an analysis with regard to blood transfusion and the use of so-called alternative ‘blood substitutes’ will be to obtain information on people' judgements of such risks [[8]]. One dominant theme in contemporary risk research is the social amplification of risk [[9]]. In this respect, the question becomes how do minor risks become exaggerated into large-scale public worries and panics? Indeed, the recent finding that key groups vary in their perception of risk [10-11] may help to explain the social amplification of risk.

In the UK, increasing concerns about the safety of blood and blood products are underpinned by advice from the Spongiform Encephalopathy Advisory Committee (SEAC), to suspend the use of plasma from British donors as a source of plasma fractions as a precaution to protect patients from the theoretical risk of contracting the new variant of Creutzfeldt-Jakob disease (vCJD) [[12]]. The attention devoted to this topic, especially by the media, may have influenced the general public' attitudes to blood safety. Therefore, the present study has gathered data on the perceived risks associated with blood transfusion, including the use of potential blood substitutes [12-13], and donation, in UK general practitioners (GPs), anaesthetists, health/lifestyle journalists and blood donors of both genders. One focus of the research was to identify the relationships between perceived risk and choice in the target groups.

METHODS AND STUDY DESIGN

The Sample Target Survey

The study design consisted of a cross sectional survey using four key stakeholder groups within the UK adult population conducted from March–July 2000: (i) GPs (n = 88), recruited via local practices within the Trent region, (ii) anaesthetists (n = 143), (iii) health/lifestyle journalists (n = 20), and (iv) blood donors (n = 250), recruited from both mobile units and drop-in centres in the Trent region. GPs were selected because they play a vital first-line role in communicating and informing the public about health issues. Anaesthetists were targeted as they prescribe the majority of blood used clinically in the UK. Health/lifestyle journalists were sampled since they play a major role in influencing public perceptions of risk associated with medical interventions. Blood donors were targeted to enable the role of past blood donation behaviour to be examined.

Risk Assessment Procedure

The survey consisted of a questionnaire in which target groups were asked to indicate their assessment of the risk(s) associated with blood transfusion and donation using a rating scale from 1 (not at risk) to 7 (very great risk). A free response also allowed respondents to identify those risks and possible infections they most associated with blood donation or transfusion. This gave an indication of what respondents viewed as determinants of risk associated with these procedures. They were invited to state ‘none’, if appropriate. Respondents were additionally asked to indicate their preference for receiving their own (autologous) blood, donor (allogeneic) blood, a blood substitute, or none of these options. They were further invited to indicate their preference for donated blood or a blood substitute. All questionnaires were completed anonymously.

Data Analyses

Means and standard deviations (s.d.) were used throughout, where appropriate. Statistical differences between group responses were determined by conventional ANOVA and Chi-squared analyses [[14]]; a probability of P < 0.05 was considered significant.

RESULTS

Responses

Blood donors (n = 250) were enrolled in person at donor sessions in both mobile and fixed sites within the UK Trent region. Questionnaires were posted to the complete list (n = 223) of teaching practice GP' within the Trent region and responses were received from 88 (40%). For anaesthetists, questionnaires were posted to all college tutor members of the UK Royal College of Anaesthetists (n = 283); responses were received from 143 (51%). All journalists listed (n = 141) in the medical section of the UK Media Directory were sent questionnaires. Responses were received from 20 (14%). Overall, the total number of respondents was 501 (male = 264, female = 233, unknown = 4), with a mean (±s.d.) age of 35.8 ± 12.6 years.

Risk Evaluation

The mean scores for the rating of risk associated with blood transfusion, on a scale from 1 to 7, are listed in Table 1. ANOVA showed no significant differences in the overall rating of risk between the sample groups, both for general and infection risk. However, the data revealed interesting variations in risk assessments between the groups. Anaesthetists gave the highest score (2.48 ± 1.21) in relation to the personal (i.e. negative health consequences) risk associated with transfusion, whilst journalists scored lowest (1.89 ± 0.94). In terms of the risk of infection associated with blood transfusion, anaesthetists scored highest (2.97 ± 1.27) and blood donors scored lowest (2.79 ± 1.24). Concerning the risk of infection associated with blood donation, blood donors scored highest (1.45 ± 0.78) and journalists lowest (1.15 ± 0.37). Overall, all respondents rated the risk associated with blood donation as markedly lower than that associated with blood transfusion.

Table I. Rating of Risk Associated with Blood Transfusion and Donation

	GPs (n = 88)	Anaesthetists (n = 143)	Journalists (n = 20)	Blood Donors (n = 250)
General risk (Transfusion)	2.20 ± 0.95	2.48 ± 1.21	1.89 ± 0.94	2.31 ± 1.26
Infection risk (Transfusion)	2.91 ± 1.31	2.97 ± 1.27	2.90 ± 1.12	2.79 ± 1.24
Infection risk (Donation)	1.34 ± 0.80	1.24 ± 0.57	1.15 ± 0.37	1.45 ± 0.78

Values are mean (± s.d.). The numbers of respondents (n) for each grouping are given in parentheses.

Respondents were asked in free response questions to state what risks and infections, if any, they associated with blood transfusion (Table 2). In relation to risks associated with transfusion in general, many donors seemed unaware of any risks with this procedure and 57% of respondents in this category stated ‘none’. Journalists seemed similarly unaware, with 42% stating ‘none’. However, the number of respondents indicating no risk was much smaller for the other groups (GPs 8%, anaesthetists 1%). Acute reactions (e.g. anaphylaxis and other allergic phenomena) were mentioned by 40% of GPs, 33% of anaesthetists, but by only 2% of donors, and not at all by journalists. Anaesthetists (53%) recognized far more than the other groups the risk of administrative error (Table 2).

Table II. Perception of the Risks Associated with Blood Transfusion

	GPs (n = 75)	Anaesthetists (n = 135)	Journalists (n = 19)	Blood Donors (n = 46)^*
None	6 (8%)	1 (1%)	8 (42%)	26 (57%)
Infection—viral	14 (19%)	21 (16%)	1 (5%)	10 (22%)
Infection—bacterial	9 (12%)	14 (10%)	1 (5%)	3 (7%)
Reaction—acute	30 (40%)	44 (33%)	0	1 (2%)
Reaction—delayed	1 (1%)	8 (6%)	3 (16%)	1 (2%)
Administrative error	18 (24%)	71 (53%)	4 (21%)	6 (13%)
The unknown	1 (1%)	1 (1%)	1 (5%)	0
vCJD	0	0	1 (5%)	1 (2%)
Death	0	0	1 (5%)	0

The numbers of respondents (n) for each grouping are given in parentheses.

^* 53 donors sampled.

Concerning the risks of infection associated with blood transfusion and donation, 46% of donors and 35% of journalists associated HIV/AIDS with transfusion; the corresponding values for anaesthetists and GPs were 6% and 5%, respectively (Table 3). Thirty percent of donors and 25% of journalists indicated that they believed there were no risks of infection with these procedures, whilst the corresponding value for GPs was 4% and for anaesthetists was 3%. Hepatitis was stated as a possible infection risk by 92% of GPs, 89% of anaesthetists; 40% of journalists and 20% of donors. Interestingly, vCJD was mentioned as an infection risk by 10% of journalists, but by only 5% of GPs, 2% of donors and 1% of anaesthetists (Table 3).

Table III. Perception of the Infections Associated with Blood Transfusion

	GPs (n = 86)	Anaesthetists (n = 141)	Journalists (n = 20)	Blood Donors (n = 226)
None	3 (4%)	4 (3%)	5 (25%)	68 (30%)
HIV/AIDS	4 (5%)	9 (6%)	7 (35%)	103 (46%)
Hepatitis	79 (92%)	125 (89%)	8 (40%)	44 (20%)
vCJD	4 (5%)	2 (1%)	2 (10%)	9 (4%)
Malaria	0	1 (1%)	0	1 (0.5%)
Unknown virus	1 (1%)	3 (2%)	0	2 (1%)
Miscellaneous	1 (1%)	4 (3%)	0	8 (4%)

The numbers of respondents (n) for each grouping are given in parentheses.

When asked to indicate the risk of infection associated with blood donation, most respondents in all groups (journalists 100%; anaesthetists 84%; donors 82%, GPs 75%) stated ‘none’ (Table 4). However, 12% of donors associated HIV/AIDS with donation, whereas the corresponding value for GPs was 1%, and that for both anaesthetists and journalists 0%. Interestingly, 12% of GPs associated hepatitis with donation, with the same response by 7% of anaesthetists and 4% of donors. Journalists did not indicate any association between blood donation and hepatitis. Similarly, vCJD was not mentioned as a possible infection risk by any respondent in any group, except for 1 blood donor. Infection at site of wound was mentioned as an infection risk by GPs (11%) and anaesthetists (8%), but not at all by journalists or blood donors. These findings indicate that key groups still perceive that there is some risk of transmissible infections entering the donor blood supply. This links across with the results in Table 2, showing that viral and bacterial infections are seen as risks in blood transfusion.

Table IV. Perception of the Infections Associated with Blood Donation

	GPs (n = 84)	Anaesthetists (n = 141)	Journalists (n = 20)	Blood Donors (n = 228)
None	63 (75%)	118 (84%)	20 (100%)	187 (82%)
HIV/AIDS	1 (1%)	0	0	28 (12%)
Hepatitis	10 (12%)	10 (7%)	0	10 (4%)
Tetanus	0	1 (1%)	0	2 (1%)
vCJD	0	0	0	1 (0.5%)
Infection at site of wound	9 (11%)	11 (8%)	0	0
Unknown virus	1 (1%)	1 (1%)	0	0

The numbers of respondents (n) for each grouping are given in parentheses.

Preferences for Blood or a Substitute

The percentage of respondents who would prefer to receive their own (autologous) blood, compared to donor (allogeneic) blood or a suitable substitute ranged from 73–94% (Table 5). When asked to choose between donor blood or a blood substitute, there were also significant (P < 0.05) differences between sample groups (Table 6): anaesthetists and GPs preferred to receive a blood substitute (52–59%), whereas blood donors and journalists would prefer donated blood (74–93%). Interestingly, when the two clinical groups were compared to the two non-clinical groups, 57% of the former stated that they would prefer a blood substitute rather than donated blood; the corresponding value for the latter was 13%.

Table V. Preference of Respondents for Own Blood, Donor Blood, Blood Substitute, or None of These Options

	GPs (n = 85)	Anaesthetists (n = 140)	Journalists (n = 18)	Blood Donors (n = 230)
Own blood	79 (93%)	132 (94%)	14 (78%)	167 (73%)
Donated blood	4 (5%)	5 (4%)	4 (22%)	58 (25%)
Blood substitute	2 (2%)	2 (1%)	0	5 (2%)
None of these	0	1 (1%)	0	0

The numbers of respondents (n) for each grouping are given in parentheses.

Table VI. Preference of Respondents for Donor Blood or Blood Substitute

	GPs (n = 77)	Anaesthetists (n = 133)	Journalists (n = 19)	Blood Donors (n = 53)^*
Donated blood	37 (48%)	54 (41%)	14 (74%)	49 (93%)
Blood substitute	40 (52%)	79 (59%)	5 (26%)	4 (7%)

The numbers of respondents (n) for each grouping are given in parentheses.

^*53 donors sampled.

DISCUSSION

The results of this study provide, for the first time, a snapshot of opinion of the perceived risks associated with blood transfusion and donation in four key UK stakeholder groups. The present findings have clear implications for the future development and implementation of modern transfusion options, including the use and acceptability of blood substitutes as alternatives to donor blood.

Important differences have been revealed in the perception of risk associated with transfusion and donation across the stakeholder groups. Whilst the overall rating of risk was fairly low, the free responses provided qualitative information about what the individual groups recognized as determinants of risk. In this study, a number of blood donors associated HIV transmission with blood donation. This finding is open to two possible interpretations namely, that donors believed they could contract HIV through donation or that the virus can enter the blood supply through donation. Scrutiny of the data revealed that of all the donors who associated HIV with blood donation, all but one of them also linked HIV transmission with blood transfusion. This therefore supports the latter interpretation of the belief that HIV can enter the blood supply via donation. However, other work in Scotland [[15]] presented evidence of the belief that HIV infection could occur during blood donation and that this fear was adversely affecting blood donation habits. A similar survey in Greece also revealed evidence of an increased perception of a link between blood donation and HIV infection among a random sample of the adult population [[16]].

In this study, anaesthetists correctly recognized the potential risk of administrative error associated with blood transfusion. In contrast, journalists and blood donors seemed relatively unaware of any risks linked to transfusion. There were also major differences in the infections each group associated with transfusion and donation: hepatitis was the main concern of GPs and anaesthetists, HIV was the major concern of blood donors, and journalists indicated that both hepatitis and HIV were the principal infection risks. This is of interest since data from the USA, for example, indicates that the risk of transmitting hepatitis per unit of blood is almost 8-fold greater than that for HIV [[17]]. It is noteworthy that, for GPs, anaesthetists and blood donors, there was a very low association (>5%) between blood transfusion and vCJD. Indeed, vCJD was identified as a major infection risk by more journalists than by any other respondent group. Whilst the sample size for journalists was relatively small, this does raise questions about the social amplification of risk within the sphere of blood transfusion. In this respect, recent evidence shows that members of different groups have different structural representations of risk [10-11].

Recent research in sheep showing that the agent causing BSE can be transmitted through blood transfusion [[18]], and the ensuing coverage in the media, may well have influenced the perceptions of the infection risks associated with blood transfusion, or with the use of animal (especially bovine) proteins in blood substitutes, amongst the target groups. This is relevant since the same agent producing BSE in cattle [[19]] causes vCJD in humans. However, because the present survey was completed prior to the publication of the paper by Houston et al. [[18]], it will be of interest in future research to determine the extent to which stakeholder perceptions may have shifted.

The present study shows clearly that, given a choice, anaesthetists are more likely to accept a blood substitute than donor blood. Indeed, the present study has further revealed the importance of both qualitative and quantitative aspects of risk perception in driving behaviour regarding the choice between donated blood and a blood substitute. Respondents who rated the infection risk associated with transfusion the highest (e.g. anaesthetists) were more likely to choose a blood substitute. It will be of interest in future research to determine whether, assuming no differences in efficacy and safety, there are preferences for synthetic (e.g. fluorocarbon-based) materials or those containing haemoglobin extracted from human or animal blood [12-13], [[17]]. Furthermore, because at least one proprietary haemoglobin-based substitute is based on bovine blood (e.g. Hemopure^™, Biopure Corporation, USA), it is crucial to determine whether this influences acceptability, given the points made already about the potential for transmitting spongiform encephalopathy infectivity through blood.

Overall, the present study has identified important issues relevant to modern blood transfusion and donation in the UK. The findings are particularly timely given the on going and increasing concerns about the safety of blood and blood products [[12]]. The information obtained from this study offers blood services a unique opportunity for positive intervention in the area of public perceptions of risk associated with transfusion and donation that should also be applicable in an international context. In particular, the information relating to areas of misunderstanding on blood transfusion and donation revealed in the free responses of this study will be useful when targeting messages to various societal groups. This will form a baseline for improved message framing which is a key area for further research.

ACKNOWLEDGMENTS

This research was supported by the UK National Blood Service.