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Indian Journal of Community Medicine

Knowlege, Attitudes and Socio-Demographic Factors Differentiating Blood Donors From Non-Donors in an Urban Slum of Delhi

Author(s): Bir Singh, RM Pandey#, N D'Souza, A Anushyanthan*, V Krishna*, V Gupta*, MM Chaudhary*, S Ganeshan*, S Jha*, S Uppal*, V Mehrara*, RD Deepchand*, Y Singh*, KM Hsia*, S Bhushan*, V Anand*, AK Singh**

Vol. 27, No. 3 (2002-07 - 2002-09)

Deptts. of Community Medicine (*UG medical students) and Biostatistics#, AIIMS, New Delhi - 110029 **UG medical student, Maulana Azad Medical College, New Delhi


Research question: What are the factors differentiating blood donors from non-donors in an urban slum?

Objectives: To assess the knowledge, attitudes and socio-demographic characteristics which differentiate donors from non-donors among residents of an urban slum in New Delhi, India.

Study design: Cross-sectional.

Methods: One member from each of 434 households in the study area was interviewed. Inclusion of subjects was based on quota sampling to obtain an equal representation in the different age and sex categories studied. Initial questions were asked to assess knowledge about blood donation. To study attitude, a culturally adapted form of the Breckler and Wiggins Equal Appearing Interval scale was used. This scale measures the cognitive, affective and behavioural components of attitude. Then, reasons for non-donation were ascertained.

Statistical analysis: Proportions, chi square test, step-wise multiple logistic regression analysis.

Results: 22.4% of the subjects studied were not even aware that blood could be donated. Only 7.7% had been ever donors. Donor status was significantly associated with age, sex, literacy status, occupation and knowledge about other aspects of blood donation. Over half of all non-donors cited a culturally indigenous fear, "khoon ki kami" or having a volumetric deficiency of blood as the reason for non-donation.

Conclusion: There exists large lacunae in basic knowledge about donation alongside indigenous misconceptions which account for the low public initiative to donate blood in this population. This needs to be addressed through education, motivation, advocacy and the correction of culture specific misbeliefs.

Keywords : Blood donation, Attitudes, Beliefs, Slum, New Delhi


Blood donors in India, largely fall into one of three categories - voluntary, replacement or professional (paid) donors. A voluntary donor is one who is not paid for the donated blood and donates for altruistic reasons. A replacement donor is also a non remunerated donor who donates blood for a particular patient in an emergency situation. Replacement donors are usually family members, colleagues or friends of the concerned patient. Professional or paid donors donate blood on payment of money.

India, with a population of over a billion, has a meagre availability of 2.5 million units of blood against a minimum modest annual requirement of approximately 6 million units (Jolly, 1994)1. A study conducted in New Delhi, the capital city of India (Makroo and Kumar, 1991) reported that nearly 40% of all donations in this city were from paid donors. They reported that only 17% of all donations were voluntary while 43% were replacement donations. Following a government sponsored study, which showed a high incidence of hepatitis-B among paid donor blood, the Supreme Court of India passed an order banning the payment of money to blood donors from January 1998 (Mudur G, 1998). This led to a further shortage of blood units in India largely because of a lack of public initiative to donate blood voluntarily. This lack of initiative perhaps could be related to general illiteracy, large families, poverty, poor knowledge of blood donation, little motivation, regional beliefs and misconceptions. Thus, this study was primarily designed to assess the knowledge, attitudes and the socio-demographic characteristics, which differentiate donors from non-donors among residents of an urban slum in New Delhi, India.

Material and Methods:

Delhi has a population of about 16 million and 35 to 40% live in slums. Ambedkar camp is one of 1200 slum clusters of Delhi and has a population of about 10,000. This slum population constitutes the field practice area of the Centre for Community Medicine (Urban Health Project) at the All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi. Ambedkar camp was divided into four equal parts using prominent geographic landmarks and one part was randomly selected for this study.

A cross-sectional study was planned and implemented so as to determine the difference in the knowledge and attitudes of donors and non-donors and the socio-demographic characteristics associated with blood donor status. All persons aged 18 to 60 years residing in the study area for at least six months were included in the study. There were 434 families in the study area that met the selection criteria as determined by a door-to-door enumeration. This number was adequate for considerations of sample size.

One person per household was selected using quota sampling so as to obtain equal representation in 4 age-sex categories at the end of a field visit. The categories were 18 to 34 years and 35 to 60 years for either sex respectively. Selected subjects were explained the purpose of the study, confidentiality assured and consent taken prior to each interview. Following each interview, the interview schedule was checked for completeness and a mark was put outside each house so as to avoid revisit.

Initial questions were framed to assess knowledge about blood donation. The subjects were asked whether they knew that a person's blood could be donated to another (closed ended). Only those who answered in the affirmative were interviewed further regarding awareness of their own blood group, knowledge of a place where blood could be donated and their perception of an inter donation interval (all open ended). They were then asked if they had ever donated blood.

The study instrument to ascertain the attitude was developed after an extensive literature search and a review of several attitude scales. The Breckler and Wiggins Equal Appearing Interval scale (Breckler and Wiggins, 1989)2 was chosen. This scale measures the cognitive, affective and behavioural components of attitude. The scale was adapted so as to make it culturally relevant to our setting. No attempt was made to calculate a total score due to the modifications made to the scale and results are reported without combining the score for individual items.

After initial questions to assess knowledge about blood donation, responses that measure attitude (cognitive, affective and behavioural components of attitude as mentioned in the scale) were elicited. The measurement of the cognitive component was assessed based on responses to four questions viz. perceptions about why should blood be donated for, perceived need for donation in society, general perception about blood donation and perceived effect of donation on the body. The affective component of attitude was measured by responses to two questions regarding the feeling about waiting in the queue to donate blood and the feeling if blood had been donated. The behavioral component of attitude was assessed based on responses to questions about the subject's willingness to donate if a blood donation camp was to be organized in their community and his/her willingness to donate if a relative needed blood. The answers to the above open ended questions were graded using a five-point Likert scale with a score of 5 being highly favorable towards blood donation, 3 being neutral and 1 being highly unfavorable.

Further, reasons for non-donation were also ascertained from donors (about non-donors) and from non-donors themselves.

Socio-demographic differences between donors and non-donors were analyzed using stepwise multiple logistic regression.


Basic socio-demography:

434 families met the selection criteria for the study, of which 32(7.4%) refused to participate as they felt that they would not benefit from participating in the study. From the remaining 402 families 119(29.6%) males and 138(34.3%) females were between 18 and 34 years, 81(20.2%) males and 64(15.9%) females were between 35 and 60 years. Sixty nine (17.2%) of the respondents belonged to Delhi, the rest were migrants. The median duration of stay in Delhi for migrants was 12 years (range 1 to 58 years). Most (72.6%) of the respondents belonged to nuclear families, 20.4% to joint families, 4.2% lived alone and 2.7% belonged to extended families. Literacy was higher among the males (69.5%) as compared to females (49.3%).

Knowledge about blood donation:

Table I: Study population characteristics and blood donation status.

Study variables Total (n=312)
Non-donor (n=288)
Statistical test values
18-34 years 193 (61.9) 8 (33.3) 185 (64.2) x2 = 8.97, p=0.002
35-60 years 119 (38.1) 16 (66.7) 103 (35.8)  
Female 137 (43.9) 5 (20.8) 132 (45.8) x2 = 5.62, p=0.017
Male 175 (56.1) 19 (79.2) 156 (54.2)  
Marital status
Married 276 (88.5) 24 (100.0) 252 (87.5) x2 = 3.34, p=0.067
Unmarried 36 (11.5) 0 (0) 36 (12.5)  
Literacy status
Illiterate 127 (40.7) 5 (20.8) 122 (42.4) x2 = 4.25, p=0.039
Literate 185 (59.3) 19 (79.2) 166 (57.6)  
Family type
Joint/extended 77 (24.7) 4 (16.7) 73 (25.3) x2 =0.898,p=0.343
Nuclear/Living alone 235 (75.3) 20 (83.3) 215    
Non-professional 288 (92.3) 19 (79.2) 269 (93.4) x2 = 6.32, p=0.012
Professional 24 (7.7) 5 (20.8) 19 (6.6)  
Know own blood group
No 278 (89.1) 14 (58.3) 264 (91.7) x2 =25.35,p=0.000
Yes 34 (10.9) 10 (41.7) 24 (8.3)  
Place for donation
Don't know 122 (39.1) 0 (0) 122 (42.4) x2 =16.69,p=0.000
Know 190 (60.9) 24 (100.0) 166 (57.6)  
Blood bank** 35 (18.4) 3 (12.5) 32 (19.3) x2 = 0.64, p=0.423
Hospital** 155 (81.6) 20 (83.3) 135 (81.3) x2 = 0.06, p=0.812
Donation camp** 58 (30.5) 15 (62.5) 43 (25.9) x2 =13.24,p=0.001
#Others** 4 (2.1) 0 (0) 4 (2.4) x =0.59, p=0.442
Inter-donation interval
Incorrect knowledge 292 (93.6) 20 (83.3) 272 (94.4) x2 = 4.56, p=0.033
Correct knowledge 20 (6.4) 4 (16.7) 16 (5.6)  

*Professional occupations include teacher, computer technician, social worker, priest and local doctor, non-professionals include carpenter, painter, potter, tailor, shopkeeper, barber, vegetable or ice-cream vendor, watchman, peon, washer man, electrician, hotel or factory worker;
**Multiple responses were tabulated, percentages total more than 100;
#Others include nursing homes and doctors' private clinics;
p value for the difference between donors and non-donors.

90(22.4%) of the 402 study subjects had not heard about blood donation or that one person's blood could be given to another. They were not interviewed further. Of the remaining 312 subjects, 34(10.9%) were aware of their own blood group. 190(60.9%) knew about a place for donating blood and most of them (81.6%) mentioned hospital as a place for donating blood followed by donation camps (30.5%) and blood banks (18.4%).

20(6.4%) had correct knowledge of the inter-donation interval and 24(6%) had donated blood before.*


Blood donors were significantly different from non-donors in their response to all questions on cognitive, affective and behavioural aspects. Though the median score was similar for 3 out of 4 questions on cognition, the differing range of answers yielded a statistically significant difference between the two groups in their response to these questions as well. Blood donors were likely to have a more favourable attitude than non-donors in their general perception about blood donation, perception about altruistic blood donation, perceived need for blood donation in society and were less likely to perceive that blood donation would harm the body. Donors were also more positive in their feelings concerning blood donation than non-donors when asked what they felt if they had just donated blood or if they were to stand in a queue to donate blood. Besides, donors were significantly more willing to donate blood for a relative or enlist at a blood donation camp.

Reasons for not donating blood:

The commonest reason given by donors (about non-donors) and non-donors themselves was `khoon ki kami'. `Khoon Ki Kami' translates into less blood and was explained as a volumetric deficit of blood rather than as a percentage decrease in haemoglobin. This indigenous misconception of `khoon ki kami' was widespread - it was expressed by more than 50% of all respondents.
Many of the respondents added that they already felt weak and that they did not have "even a drop of blood in their bodies". Fear of disease, not having the opportunity or not being one's responsibility were other responses also mentioned by both donors and non-donors.

Factors associated with blood donation:

Blood donor status (Table I) was significantly associated with age, gender, literacy status, occupation, knowledge of one's own blood group, knowledge of inter donation interval, knowledge about a place for donating blood and identifying a donation camp as a place for blood donation.*

Table II: Study population characteristics and unadjusted OR (95% CI) and adjusted OR (95% CI) using multiple logistic regression taking blood donor status as an outcome variable.

  Unadjusted Odds Ratio
(95% CI)
Adjusted Odds Ratio
(95% CI)
18-34 years 1.00 1.00
35-60 years 3.59(1.49-8.68) 4.66(1.75-12.43)
Female 1.00  
Male 3.22(1.17-8.85) 3.27(1.09-9.76)
Literacy status
Illiterate 1.00 -
Literate 2.79(1.01-7.69)  
Family type
Joint/extended 1.00 -
Nuclear/living alone 1.70(0.56-5.13)  
Occupation* -
Non-professional 1.00 -
Professional 3.73(1.25-11.08)  
Know own blood group
No 1.00 1.00
Yes 7.86(3.15-19.57) 9.52(3.48-26.06)
Inter-donation interval
Incorrect knowledge 1.00 1.00
Correct knowledge 3.40(1.04-11.13) 2.99(0.83-10.76)

*Occupation as in Table I.

As seen from Table II, those who were older (35-60 years), male, literate, professional and had correct knowledge about the inter-donation interval were about 3 times more likely to donate blood as compared to those who were younger (18-34 years), women, illiterate, non-professional and incorrect knowledge of the inter-donation interval respectively. Those who lived in nuclear families or lived alone were 1.7 times more likely to donate blood than those who lived in joint or extended families, whereas, those who knew their own blood group were nearly 8 times more likely to donate as compared to those who did not.

The adjusted odds ratio was also calculated (Table II). Those who knew their own blood group were nearly 10 times more likely to donate as compared to those who did not know their own blood group, all else remaining constant, i.e., if they were 18-34 years, female or with incorrect knowledge of the inter-donation interval.


Our results suggest that there are large lacunae in basic knowledge about blood donation among the population. 22.4% (90 of the 402) of the subjects interviewed were not even aware that one person's blood could be given to another. Over a third of the remaining 312, (39.1%) could not identify a place to donate blood. These large gaps in knowledge and awareness could be the starting point for initiating information, education and communication (IEC) activities to promote public participation in blood donation.

Of the 60% of subjects (190/312) who knew where blood could be donated, most (81.6%) identified hospitals, whereas, blood donation camps were identified only by 30.5%. These figures emphasize that in our setting, the act of donating blood is more often identified with replacement donation (hospitals) than with voluntary or altruistic donation (camps). This is in accordance with studies which have observed a low percentage of voluntary donors in developing countries compared to more developed nations (Wake and Cutting, 1998)

In our study, the prevalence of those who had ever donated blood at some time in the past was 6%. These low levels of participation were despite relatively higher levels of awareness about blood donation (77.6%) suggesting a role for motivation, advocacy and the introduction of social incentives to voluntary donors such as printing of their names in the local newspapers or felicitation at a public function. The gap in the awareness (cognition) and practice (behaviour) was seen in our findings. Participation was much lower than in other community based settings in the Western world, where, the prevalence of ever donors ranged from 36% (Thomson, 1993)3 to 40.8% (Chliaroutakis et al, 1994)4. This large difference in participation between our study and other reported literature is perhaps related to our study setting being an urban slum.

Non-donors as much as donors had high levels of cognition which were favorable for blood donation, except for the perceived effect of donation on the body, which is discussed subsequently. Questions that measured affect or behaviour differentiated between donors and non-donors to a greater extent. These findings are in agreement with those of other studies that have measured cognition, affect and behavioural aspects of attitude separately (Wake et al5, 1998; Rajagopalan et al6, 1998).

Our study also revealed that a major reason for non-donation was the perception of a harmful effect of donation on the body. This perceived fear appears to be reflected in the commonest reason given by donors about non-donors (50.0%) and non-donors themselves (53.5%) for not donating blood. Blood to the lay public appears to be a precious commodity in short supply where malaise or weakness or fatigue after a hard day's work was perceived to be due to `khoon ki kami' or a volumetric deficit in blood. Although studies assessing reasons for non-donation from other parts of the world do report a fear of blood donation adversely affecting health (Chliaroutakis et al; Fernandes-Montoya et al7; Leibrecht et al8), this indigenous fear (khoon ki kami or a volumetric deficiency of blood) has cultural connotations which will need to be addressed in culture specific advocacy messages. In response to the question about why they had not donated blood before, a quarter of all non-donors (25%) said they had not felt the need to donate. This response reflects a situation in which blood is donated largely for a family member in need (replacement) and implies that donation for any other reason (altruism) is a low priority.

In our study factors such as age, gender, literacy status, occupation, knowledge of one's own blood group, knowledge of inter-donation interval, knowledge about a place for donating blood and identifying a donation camp as a place for blood donation were significantly associated with donor status. Similar variables have been identified to be associated with blood donation in other studies (Condie et al9, 1970; Oswalt et al10, 1975). In our setting, men were more likely to donate blood than women. this finding is possibly due to patriarchal nature of Indian society especially prevalent in this region of the country. Older individuals were also more likely to donate in a situation where majority of donations are replacement donations probably they being the eldest members of large families and with substantially more responsibility to the family. Professionals, being educated were more likely to donate than skilled or unskilled illiterate workers. Those who had correct knowledge about their own blood group, the inter-donation interval and were aware of blood camps were more likely to donate as compared to those who did not. This may be the effect of prior contact with the health system rather than the above knowledge per se contributing to favorable behaviour.

In conclusion, the significant findings of our study were the ignorance of the population of basic knowledge about blood donation, a very small number of ever donors and the presence of widespread indigenous misconceptions. An obvious shortcoming of our study that might have affected our results was that it was conducted in an urban slum consisting of a largely illiterate and migrant population, who do not have an assurance of a reasonable standard of living. Nevertheless, low public initiative to donate blood needs to be addressed through dissemination of basic and proper knowledge on the safety and importance of blood donation, sensitization of the population using motivational advocacy messages, introducing culturally relevant social incentives to voluntary donors, launching promotional programmes with an emphasis on the elimination of certain indigenous misconceptions regarding blood donation.


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