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Social capital, trust foundation and risk construction as social determinants of blood donation Fiddler, Jay A. 2003

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S O C I A L CAPITAL, T R U S T F O U N D A T I O N A N D RISK C O N S T R U C T I O N A S SOCIAL D E T E R M I N A N T S OF B L O O D D O N A T I O N  by  J A Y A. F I D D L E R B.A., Carleton University, 1997 A THESIS S U B M I T T E D IN P A R T I A L F U L F I L M E N T OF T H E R E Q U I R E M E N T S FOR T H E D E G R E E OF M A S T E R OF A R T S in T H E F A C U L T Y OF G R A D U A T E STUDIES (Department of Anthropology and Sociology) We accept this thesis as conforming to the required standard  T H E U N I V E R S I T Y OF BRITISH C O L U M B I A August, 2003 © Jay A . Fiddler, 2003  UBC  Rare Books and Special Collections - Thesis Authorisation Form  http://www.library.ubc.ca/spcoll/thesauth.html  In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d b y t h e h e a d o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I ti s understood t h a t copying or p u b l i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n .  Department o f (  StY?!  Z ) / DjLj  The UUnniivveerrssiittyy o f B r i t i s h V a n c o u v e r , Canada  j  //)  /17VO  fO^f^  Columbia  Date  1-ofl  27/08/2003 9:45 A M  Abstract  Understanding blood donor motivation has been the focus of much research in the past decade. To date the majority of this research has focused on individual factors related to altruism and "altruistic identity". Although important, such knowledge has been unable to produce an increase in blood donors. One aspect of blood donation that has been under-explored is the role of social determinants in blood donation. Current data demonstrates the demographic differences in blood donor rates by race, ethnicity, gender, age, geographic locale, community and income. Such findings suggest that it is important to understand how social factors influence donation. Thus, this paper is premised on the idea that blood donation is best understood through an examination of the social context in which decision to donate blood occur. In order to conceptualize the social context of blood donation, I utilized the theoretical perspectives of social capital, trust foundation and risk analysis. Such perspectives provided an important framework with which to understand both donation and non-donation. Current CBS data indicates that community-based donation programs are more effective at stimulating continued donation than are individual-based programs. As well, academic literature has demonstrated that issues of trust and perceptions of risk are mediated when donation occurs in a community-based setting. Such findings challenge the notion of individual altruism as the main explanatory factor in blood donation. Instead, demonstrating how social factors including community and social network relationships provide motivation to donate that altruistic appeals do not. Therefore, decisions to donate cannot be removedfromthe social context in which such decisions occur.  11  Table of Contents Abstract  ii  Table of Contents  iii  Chapter One: Introduction  1  Chapter Two: Existing Research Dealing with Blood Donation  8  Psychological analysis of blood donation: identity and altruism  8  Demographic analysis  20  Social structural analysis  22  Summary  26  Chapter Three: Non-donation, Deferral and Lapsed Donation  28  Research on non-donation  28  Impact of deferral on continued donation  31  Lapsed donation  32  Summary  33  Chapter Four: Alternative Perspectives on Blood Donation  35  Social capital  37  Social capital and community  40  Ethnicity and blood donation  42  Willingness to trust and perceptions of risk  45  Social capital, blood donation and voluntarism  48  Chapter Five: Conclusions and Contributions to Future Knowledge  50  Bibliography  59  iii  Chapter One; Introduction  The blood industry in Canada has faced many challenges in the past 15 years. With the emergence of new pathogens such as HTV, Hepatitis B and C, West Nile virus and variant CJD, there has been a need to incorporate safety precautions and policy changes which have resulted in a decline in eligible donors. The struggle to recruit and retain much-needed donors has been caused in part, to a lack of knowledge surrounding the decision-making process with regard to donating blood. Current research indicates that the Canadian Blood Service needs to increase its donor  base by 40% by the  year  2005 to  meet  the  looming blood  shortages  (www.bloodservices.ca). The consequences of a continuing lack of available blood and plasma are severe , including delaying surgery for accident victims, cancer patients and those in need of organ transplants. It is fundamental to the health of Canadians that this increase in donors be met. In Canada, as elsewhere, there is a lack of systematic social research on blood donation. The existing Canadian research has consisted of opinion polls by the Canadian Blood Service (CBS) to determine demographic characteristics of donors and public opinions regarding blood donation. Although somewhat informative, these have failed to investigate the social processes that lead people to engage in blood donation. This lack of understanding is especially highlighted when current polls indicate that 85% of Canadians would consider giving blood, 87% believe that there is not enough blood being donated (Ipsos-Reid, 2000), yet only 3.0% of Canadians (and 2.4% of British Columbians) give blood (CBS, 2002). Though Canadians declare that giving blood is important and have an understanding of the implications of a shortage of blood, there is still a lack of commitment to become a donor. A mere 9% of all Canadian donors are first time donors, of whom 43% never return to make another donation (CBS, data warehouse, 2002). Thus, the majority of donations (91%) are collected from a small group of repeat blood donors (CBS, data warehouse, 2002). The aim of this research project is to provide an understanding of the social structural influences on blood donation.  The premise of this project is that blood donation is best 1  understood through an examination of the social context in which this act occurs, seeing donation as a result of meaningful social and cultural relationships, rather than resulting from individual altruism. This project is intended to review the literature about blood donation and identify key research issues and questions that have been under-explored in the existing blood donation literature. The starting point for research on blood donation must begin through an examination of the relationship between altruism and giving blood.  In Canada, since 1947, when the Red  Cross's blood program was launched, donors have given blood "for no reward other than altruism" (Gray, 1997: 779).  Therefore, most of the voluntary blood systems have relied  exclusively on notions of altruism to motivate donors to give blood. This reliance upon altruism as a motivation to donate blood is due, in part, to the fact that blood donation in Canada is done voluntarily rather than in return for payment. Elster (1990), argues that because blood is supplied by volunteers who receive no immediate reward, donation can be seen "as the purest example of altruistic behaviour" (Elster cited in Healy, 2000: 1633).  Possibly for this reason, much of the  blood donation literature has tended to emphasize the individual factors related to altruism and "altruistic identity" (Piliavin and Callero, 1982; 1987; 1990; 1991; Lightman, 1981 Oswalt, 1977; Boe and Ponder, 1981), as an explanation for donation. The appeal of altruism to explain motivations to donate is particularly evident when one examines the emphasis on individual responsibility for blood donation as witnessed in blood donors campaigns. Yet, to date, such altruistic appeals to individuals have not been entirely successful in recruiting new donors. The current national rate of blood donation has remained steady at 3% for the past four years (CBS, data warehouse, 2003). Thus, research needs to explore whether donation and non-donation might better be understood through an examination of the social context in which donation occurs. This would allow the identification of the social processes that serve to motivate some while acting as barriers to others.  2  Both academic research and data collected through the CBS provide evidence that something social is behind both donation and non-donation. Donor profiles and donation patterns collected by the CBS highlight the significant differences in donation rates by community and geographical locale, as well as by age, gender and education (CBS, data warehouse, 2003). As well, academic research points to different rates of donation by ethnic and racial groups (Boulware, 2002; Glynn, 2002); along with religion, occupation and income (Healy, 2000; Piliavin and Callero, 1991; Wu, 2001). These data seem to suggest, as Healy (2000) has argued, that if indeed individual altruism were such a strong explanatory factor in donation, one might anticipate that rates might not be as influenced by social context as appears to be the case. Thus, while accepting findings that individual motivations, such as altruism, do indeed play a role in blood donation for some individuals (Piliavin and Callero, 1991), the aim of this work is to focus on the social context within which such actions have their foundations. By exploring the role of the social processes that influence decisions to donate, we will explore the motivations and barriers of both donors and non-donors. In order to conceptualize the social context of blood donation, the proposed research will examine the extent to which processes of social capital formation influence blood donation. The social capital perspective examines individuals' actions in the context of their social relationships known as social networks (Lin, 2001). According to Putnam (1993; 2000), it is the norm of generalized reciprocity that fuels social trust.  This is the trust, possessed by community  members, that their short-term altruistic actions that contribute to others' welfare, will be rewarded at some point in the future.  Hence, social capital develops through such network  relationships primarily in the patterns of trust and reciprocity that develop, the outcomes of which are various forms of collective action.  Simply put, when people are involved in social  relationships that they trust, they are motivated to maintain these social relationships and act in the broader interest of the group. Thus, a study of blood donation from the perspective of social capital research focuses on how the networks in which individuals are involved, provide the  3  framework which guides their blood donation behaviour. It examines the extent that such social network relationships become significant influences on participation in blood donation, and how these are linked to broader issues related to understanding of trust and reciprocity, and perceptions of risk Most blood research has focused almost exclusively on the motivations of donors, paying little attention to those who do not donate. Yet, in order to raise donation rates it is important to focus on the majority of the population who do not donate blood. To determine what challenges exist for participation in blood donation, the CBS has conducted polls of both the general public and current donors. In the most recent survey completed for the CBS, it states, "increasing blood donation may be less about motivating and more about removing barriers" (Ipsos-Reid, 2000: 3). The majority of Canadians know that donating blood saves lives and is something that everyone should do. As well, eight in ten Canadians say that they would consider donating in the future (Ipsos-Reid, 2000: 3). With these findings, the CBS rightly asks, "so what is keeping them from doing so?" (Ipsos-Reid, 2000: 3). According to their findings, the two main barriers to donation were identified as: time and safety (Ipsos-Reid, 2001: 3). The results show that the number one reason for not donating was "not enough time" (Ipsos-Reid, 2001: 4). Forty-three percent of those polled stated that they would donate blood if they had more time  (Ipsos-Reid, 2001). The indication of time and  inconvenience as barriers to donation may well point to a lack of belief in the importance of blood donation within Canada. Although Canadians continue to state that blood donation is important, it does not seem important enough to be something to which they contribute. Therefore, it may be that time/inconvenience is being used as a justification for not wanting to donate blood rather than existing as an actual barrier. The poll findings also identify safety as a challenge to participation in blood donation. This finding is somewhat troubling in that it seems to contradict the survey findings in which 84% of Canadians said they consider the blood system to be safer than it was five years ago and  4  90% say they believe donating blood is safe (Ipsos-Reid, 2001: 3).  This may represent a view  that, while it is considered theoretically safe, the average Canadian may feel that it is not safe enough to commit to donating blood. A continued remembrance of the "tainted blood scandal" and the emergence of new and dangerous pathogens such as VCJD (variant Creutzfeldt-Jacob disease) and West Nile virus may contribute to the ongoing safety fears of the general public. In order to explore the public's construction of risk in the blood system, a risk analysis will be employed. The construction and perception of such risk is well documented in the academic literature (Beck, 1992; Giddens, 1991; Lupton, 1999; Slovic, 2000; ).  The "risk  society" emphasizes that there is a growing awareness by citizens of their exposure to risk, to the point that risk awareness is becoming an all-pervasive aspect of industrial society.  Therefore,  although little research has been done on the role that risk perception plays in donor motivations, it seems evident that such an examination is required to determine how this influences the decision to donate blood. If safety is identified as a barrier to donation for many Canadians, how do these risk perceptions differ for donors? In conjunction with a social capital perspective, one may ask: How can the norms of trust and reciprocity help to overcome risk perceptions associated with blood donation? While the identification of these barriers is informative, there seem to be many issues surrounding blood donor participation that have not been highlighted by these polls.  Due to the  high percentage of Canadians that would consider giving blood, combined with the apparent belief in the safety of the system we should be seeing an increase in the amount of people donating. Yet the numbers have not risen. This suggests, that other factors, still unknown, must be influencing the decision-making process.  5  Research Questions  As stated previously, this research begins from the idea that blood donation can best be understood through an examination of the social context in which decisions to donate blood occur. Therefore, although research has shown that altruism plays an important role for some individuals in the decision to donate, this research aims to explain both blood donation and nondonation in a broader social context. If this research is to have relevance, it must explore how the social processes in the decision to donate are potentially different from those involved in nondonation. In order to understand how the social processes differ for donors and non-donors, this research will attempt to explore how decisions to either donate or not donate blood may result from relationships of trust and reciprocity as suggested by social capital analyses rather than individual altruism. Consequently, the first research question is as follows: How are the social processes that influence some people to donate different than those that lead others not to donate? An extension of this question, directly related to the processes of social capital, asks: Is blood donation better understood as a representation of social relationships established on trust and reciprocity rather than individual altruism? With the aim of understanding non-donation, so as to potentially increase the available donor pool, research on blood donation must attempt to understand factors that impede donation. Although survey research has identified risk, fear and safety as important factors in non-donation (Ipsos-Reid, 2001; Piliavin and Callero, 1991; Farrell, 2002; LoBello, 1990) it has not explored how these experiences differ for donors. Therefore, using a risk analysis, in conjunction with social capital, the second research question asks: How can the trust established within social network relationships mediate perceptions of risk that stand as a barrier to donation? In the upcoming chapters two and three I will explore the existing social research on blood donation and non-donation. This analysis is important as it provides a basis for comparison between the existing knowledge and areas that require further study. Chapter four will outline the  theoretical framework that will guide the research and provide a basis for exploring the social determinants of blood donation. The final chapter summarizes the conclusions drawn from a review of the literature, highlighting areas that require further study and the framework in which to explore such research.  7  Chapter Two; Existing Research Dealing with Blood Donation  Social science research related to blood donation may be categorized under the following themes:  1) Psychological analysis of blood donation (altruism); 2)Demographic analysis; 3)  Structural analysis.  Psychological Analysis of Blood Donation: Identity and Altruism  Much of the social psychology literature on blood donation literature has focused on the connection between altruism and blood donation, specifically, on the relationship between self concept, identity and altruism (Piliavin and Callero, 1991, 1990, 1988; Lightman, 1981; .Oswalt, 1975, 1977; Elster, 1990; Fernandez-Montoya, 1997; Glynn, 2002). Blood donor motivation research has focused almost exclusively on individual altruism as the major explanatory factor in the decision to donate, with little attention being paid to the important social structural and social process influences of donation. This is not to suggest that this relationship has no basis - most donors, when asked, will give altruistic and humanitarian reasons for being motivated to give blood (Piliavin and Callero, 1991; 1990; Lightman, 1981; Glynn, 2002). For example, Glynn et al (2002), in a study of 52,650 donors, found that 81% of donors said they gave because "it was the right thing to do", whereas 39% said, "I heard blood was needed" as justification for donation (p.218). Yet, a social act such as blood donation, should pay attention to the social structural nature of such a decision, rather than seeing it as the sole product of an individual decision. Piliavin and Callero have conducted much of the work in this field and therefore offer a starting point to examine this relationship. Their text, Giving Blood: The Development of an Altruistic Identity, is the result of a ten year study attempting to identify the transformation of identity that occurs through repeat donation, resulting in the creation of a "blood donor identity  8  role" (1991). They identify that the focus of their study is regular donors, committed to what they call their "altruistic career" (p.3). In Piliavin and Callero's research, the development of altruism and altruistic identity is linked in part, to the shift in blood collection philosophy. Under this new system, "the appeal is made to each individual's moral sense of responsibility toward others in their community" (p.2). They argue that,  "because most blood is now collected under a community responsibility  philosophy" rather than the old paradigm of individual responsibility, " donors of whole blood can be viewed as altruists" (1991: 3). This argument is reminiscent of Titmuss' , in that a shift away from individual rewards (whether that be family access to blood or money for blood), to one that represents community wide need, results in a system that is reliable and based upon altruism.  Although it is hard to  determine if this shift actually represents a move towards an altruistic based collection, it does seem to suggest that there exists an inherently social aspect to donation. The appeal to a less than individualistic motivation, but rather one that is couched in the needs of community, represents the important social dimension of this activity. Although much blood is collected through an appeal to societal and community need, the focus of such appeals and the research used to generate them, tend to focus on the individual's role in participation rather than to see participation in blood donation as a social commitment generated within communities or social network relationships. This is conceptually problematic as blood donation occurs within a social context, and the altruistic appeals to give blood are inherently social in nature. Indeed, what could be more social than giving to an unknown other? Therefore, it is important that blood donation research pay attention to the social nature of this decision. The focus of Piliavin and Callero's research is to examine "self variables including, "attitude, beliefs, behavioral intention, emotional response, physical reactions, personal norms, self-definitions, self-attributions, role salience, and role merger" (1991: 200).  The most  9  prominent self variables that emerged from their data were those linked to identity and role, particularly the "blood donor identity role".  However, Piliavin and Callero also emphasize the  importance of situating this concept among time, social structure and situation understanding that these concepts are mutually dependent. Situation variables include both the physical aspects (collection site, atmosphere) and social aspects (deferral, collection staff, interaction with other donors) that influence donation. Social structure refers to, "general aspects of the setting that transcend specific situational and self differences and reflect important features of the local community, the larger society, and our culture" (1991: 204).  Social structure also includes  community norms and social meanings of being a blood donor.  Time is described in the  traditional sense as in the passage of time during which a blood donor identity is created. The category of time is reflected in the transformation of a first time blood donor to a regular donor, a developmental effect that, we suggest is related to situational and social structural influences on donation.  Extrinsic vs. Intrinsic Motives The major focus of Piliavin and Callero's research is to identify the transformation of identity that occurs as a result of repeat donation, which results in the development of an "altruistic identity" or "blood donor identity role". One of the most important influences on this transformation of identity is the shift from external to internal motivations that happens through continued donation. In their work, intrinsic motives are defined as "reasons that come from inside the person and have to do with values, interests, and one's sense of responsibility", whereas, extrinsic motives are defined by "reasons that are based in the actions of others and the structure of the social world" (Piliavin and Callero, 1991: 12). In order to demonstrate this shift, they examined 782 donors responses to donation comparing first time donors to those who had given four times or more. The variables they examined included: coming in alone or with others, moral obligation, not to disappoint, enjoy 10  helping, feel good and responsibility (1991: 50). Thefindingsrevealed that among all categories of donors (from first donation to four or more), the only significant variables were "not to disappoint" (an external motivation) and "responsibility" (an intrinsic motivation).  The  percentage of respondents who stated "responsibility" for reasons to donate increased from 36.8% in the first donation category to 48.9% in the four or more category with a significance of p<.05. In contrast, those who chose "not to disappoint" as reason for donation decreased from the first donation to four or more, 24.5%to 13.2% respectively with a significance of p<001(1991: 50). These findings demonstrate the continued importance of external motivation throughout the donation career. For Piliavin and Callero (1991), the concepts of intrinsic and extrinsic motivation are not only fundamental in demonstrating the apparent shift in donor motivation and ultimately identity, but are also seen as important to continued donation.  Some research has indicated that  individuals that give blood as a response to external motivation are less likely to return than donors who give for intrinsic reasons (Piliavin and Callero, 1991; 1990; 1988; Lightman, 1982; Glynn, etal. 2002; Oswalt, 1975; 1977). In a study of 782 first time donors at the University of Wisconsin in 1978-79, Piliavin and Callero found that of those donors who cited external reasons for donation, only 31.7% returned within six months as compared to 58.5% of those who gave intrinsic reasons for donation (Piliavin and Callero, 1991: 101). Although this suggests that intrinsic motivation may indeed guarantee a larger return of donors, those whose motivations were external and yet returned for a second donation are not examined. Therefore, one is left without an understanding of how external motivation may be influential for some donors. As well, since there is a lack of research on group or community-based donation, one is unable to say if, for some donors, external motivation such as group membership and social networks may provide not only initial motivation, but also continued motivation to donate. One problem with Piliavin and Callero's research rests in the definitions used to describe the concepts of intrinsic and extrinsic motivations. An explanation and description of how they 11  came to define each concept is not available in their research. Therefore, it is unclear as to why intrinsic is related to altruism and self-based actions yet extrinsic includes the "structure of the social world" and thus, by definition not related to altruism. For them, altruism is considered an intrinsic motive, yet it seems evident that such a motivation is by all means social in nature. If, as they argue, the shift in blood collection to one that was individual based to a system that is based upon community needs, resulted in altruistic donors, then it would seem that such motivations should be linked to the social world and seen as a social activity. This is not to suggest that Piliavin and Callero do not see blood donation as a social act, yet their analysis of internal motivations seems to somewhat ignore the contribution of the social in such a decision. One example of this can be found in an important variable they use to demonstrate the transformation from external to internal motives.  For them, an important step in demonstrating the  transformation from external to internal is whether a donor has come to donate alone or as part of a group. They argue, "we assumed that the donor who comes in with others is in part giving as a social activity, and thus may be less internally motivated than is the donor who comes in alone. A person who changes his or her habit of donation from a group activity to a solitary one may be demonstrating a change in motivation" (1991: 56-57). Looking at donation in such a way is problematic in two ways. First, if indeed altruism can be viewed as a social act, then giving blood as a social activity should not necessarily mean a person has not internalized such motivations as altruism. It is not clear from their discussion if they are trying to suggest that donors who participate in blood donation as part of a group are somehow less internally and thus altruistically motivated than those who donate alone. There is no solid explanation of how donating as part of a social group or social activity negates altruism. Second, by focusing on donors coming alone to give blood there is no real value given to the importance of one's social network as influential to blood donation. It may be possible that for some individuals, this group identity is valuable for providing motivation not only for first donation, but also continued donation.  Using donation as a social act may help to sustain  12  donating behaviour for some people who have strong community or group ties. This does not suggest that altruism is not important, or possibly explanatory, but that it plays a very different role for some donors. Donating within one's community or as a member of a social group may still reveal altruistic intentions but that such intentions are given more value when carried out within the context of social relationships that are important to individuals. Finally, since Piliavin and Callero (1991) argue that intrinsic motivations are important to continued donation, this suggests that external motivations somehow impede continued donation. Although research has shown that those donors who cite external reasons for donation have lower return rates (Piliavin and Callero, 1991; Glynn et al, 2002; Lightman, 1982), with such scant literature available on group and community donation, it is hard to determine if there exist other factors that are impeding this decision to participate. Since most blood collection strategies and research have focused on individual donors, with little attention given to group donation, there has been a lack of understanding as to how decisions to donate may differ within these social contexts. Though most donors will cite altruistic reasons for donation (Piliavin and Callero, 1991; Lightman, 1981 Glynn, 2002; Oswalt, 1975; 1977), research has found that the influence of altruism plays a very different role in first time donors when compared to "career donors" with more experience in the donation system. Extrinsic motivation including social pressure, number of friends who donate and rewards such as coupons and raffles seem to work better to motivate first time donors than those who are regular donors. On the other hand, altruistic communication before donation was found to enhance the likelihood of future donations only for donors who had given before, not among first-time donors (Piliavin and Callero, 1991; Charng, 1988; Glynn, 2002). Therefore, although most donors cite altruistic reasons for donating (Piliavin and Callero, 1991: 15), Piliavin and Callero argue that, due to thesefindings,it may be that "altruism is a form of rationalization" rather than a motivation for first time or early career donors. From a sample of  13  782 college donors in 1979, 75% of those who gave initially for internal reasons but have not returned, now deny any internal impetus to their first donation (Piliavin and Callero, 1991: 57). The occurrence of such rationalization points to significant areas that blood donor research must explore. First, it seems reasonable to suggest that researchers are not able to accept the answers people give when asked why they do or do not give blood. An example emerges from public opinion polls, of both donors and the general public, conducted for the CBS by IpsosReid. These polls indicate the two main barriers to donation are 'time' and 'safety' yet, the same polls indicate that 77% of Canadians believe the blood system is safer than it was five years ago and 90% of Canadians indicate that they believe the process of donating blood is safe (IpsosReid, 2001: 3). Highlighting safety as a barrier to donation seems to contradict what the public is saying. Therefore, it seems reasonable to assume that either issues of safety and risk are being used as excuses not to donate, or risk perceptions and consciousness are impeding the decision to donate blood. This discussion will be continued in Chapter 3, which focuses on non-donation, deferral and lapsed donors, blood resear A second aspect that is under-explored in blood donor research, is related to the meaning attributed to participation in such an act. Within most voluntary blood systems, the act of donation is usually attributed to altruism. As a result of this, most research and current blood collection strategies have maintained an almost singular focus on understanding donor motivation. Healy (2000) argues that this search for "elusive altruists" is problematic, as it may steer research away from other social factors that influence donation and have not been identified in such social psychological analysis of donation. "The institutional underpinnings of the blood supply have been almost entirely overshadowed by the image of the individual altruist" (Healy, 2002: 1634).  Indeed, the perceived relationship between altruism and blood donation is  mentioned in almost all research on blood donation (Piliavin and Callero, 1991, 1987; Titmuss, 1972; Healy, 2000; Glynn, 2002; Elster, 1990; Leibrecht, 1976; Oswalt, 1975; 1977). Hence, it  14  seems reasonable to suggest that people may use altruism as an explanation for their participation as it is the only acceptable meaning within most blood collection systems.  Blood Donor Identity Role An important aspect of the social psychological literature on blood donation is the identification of a blood donor identity role that occurs through repeat donation and a shift from external to internal motivation (Piliavin and Callero, 1990, 1991; 1988; Chamg, 1988; Lightman, 1982; Glynn, 2002). Although much of the research cites the existence of such a role, most often this is done in reference to the work of Piliavin and Callero's 1991 study. They are the sole researchers that have explored the existence of this role in depth. According to Piliavin and Callero (1991; 1990), this role is identified as a social role that is represented in society, meaning "that it represents a generally stable and recurring pattern of social relationships that is recognized as a legitimate or real aspect of the community" (Piliavin and Callero, 1991: 137). The blood donor identity role is thought to occur somewhere around the fourth donation and is the result of merging this role with one's self- definition. Although many variables indirectly affect donation, including self-description as a donor and  having more  friendships tied to donation, the development of role merger is primarily the result of just two factors: other's expectations and blood donation (1991: 154). Although Piliavin and Callero state that this identity represents a shift from external to internal motivation, the variable of "other's expectations" motivation throughout their research.  is used to represent an external  Therefore, along with demonstrating the importance of  external motivations for some donors throughout the donation career, it also supports the idea that blood donation is a social act and that research must pay attention to the relationship between the individual and the social and, thus, examine altruism as a social commitment rather than an individual act.  15  The blood donor identity role is not one that all regular donors adopt, yet, Piliavin and Callero's (1991), research is not able to explain why this may not occur. Their research only examines those individuals who have taken on this role and does not refer to the majority donors for whom this role is not recognized. Although the existence of this identity gives insight into a small group of donors, it gives little understanding into determining why many people without such an identity do donate nor why a large majority of potential donors do not donate at all. One explanation for why many donors may not adopt this identity may be related to the assumption that blood donation is recognized as a "legitimate or real aspect of the community". This seems to ignore the social realities of many communities. Research indicates that for many individuals, particularly from ethnic or lower socioeconomic communities, this role may not exist as a result of fear of donation due to perceived risk, lack of awareness of the need for blood and potential loss of physical vitality (Boulware, 2002). As well, many ethnic communities or new immigrant communities may not have experience with donation and, therefore, this role would not be recognized as valid or even meaningful within their communities. As Piliavin and Callero state, "a role must be a shared community object...[it] cannot exist without the recognition of others" (1991: 143).  Therefore, if blood donation has no history or shared value within a  community, this identity or role would hold little meaning. The psychological literature on blood donation, while trying to determine the psychological roots of donation, has not entirely ignored the role of social structure and social influence on donation. Piliavin and Callero situate self variables within a larger framework that includes social structure, time and situation. Yet their analysis of the shift in donor motivation highlights a transformation that begins from the external, which is rooted in the social world, to one that results in motivation that is self-based and therefore less influenced by social obligation. In their research they have tended to minimize the influence of social factors as being somewhat influential early in the donation process and then having little importance as the donor career develops (Piliavin and Callero, 1990; 1991; Lightman, 1982). Piliavin and Callero (1991) argue,  16  "early career donors are influenced more by external factors such as perceived expectations and friendships, while an experienced donor's motivation is more likely to be self-based" (1991: 161). With that said, they do acknowledge that donation rates cannot be fully explained at an individual level, pointing to structural limitations as opportunity, language barriers and health requirement. As well, they assume that factors independent of the psychological decision-making process affect community patterns of blood donation. In order to focus on concepts that fit with their theoretical model the social structural analysis is focused on the characteristics of communities, as reflected through "social norms" , that influence donation. In order to examine the influence of social norms, they focus on community-level variables that affect blood donation. In their analysis, they found a strong effect of community norms on personal norms, thus, "if an individual perceives that their community holds a strong normative structure supporting blood donation, they are more likely to develop a sense of personal moral obligation to give" (1991: 187). This perceived expectation of community norms is tied to the individual commitment process, in which they found that perceived expectations of others was central to the development of a blood donor identity role. The research indicated that people were more likely to donate blood if they lived within communities that had strong norms associated with blood donation.  Therefore they argue; "differences in donation rates across  communities result largely from differences in social structure, particularly that aspect of social structure reflected in established communities norms related to blood donation" (1991: 180). While agreeing that the normative system is not the only feature of the social structure that influences blood donation, to them it is critical in that it has "its determining influences through the social psychology of the individuals, and it is the social psychological level that we have been primarily concerned with in our explanation of the cornrnitment process" (1991: 192). Research tends to demonstrate that external motivations such as social pressure from family and community, are important for initial or first time donation, yet play little to no role in continued donation (Piliavin and Callero, 1991; Glynn, 2002; Boulware, 2002; Oswalt, 1975;  17  1977; Surgenor, et al., 1978; Foss, 1983). Nevertheless, much of the data suggest that such social factors continue to play a role in donation throughout a donor's career (Piliavin and Callero, 1991, 1990; Glynn etal., 2002; Foss, 1983). One example can be found in blood collection drives within small communities. Without a permanent clinic, some rural communities have blood clinics that visit two to four times yearly, and the community organizes "fair days" in order to collect blood. This can be especially important in smaller communities due to the power of social norms, which will bring out donors as well making it social and convenient to donate, regardless of where in the donation "career" a person is situated (Piliavin and Callero, 1991:63). This type of example supports Piliavin and Callero's arguments that community norms associated with blood donation may influence decision to donate. Yet, we are unable to know if such individuals would continue donating outside of their respective "community", or if the very act of donation is reliant upon these social relationships. Although participating in donation within these contexts does not negate the existence of altruism, it suggests that altruism may play a very different role when one is making a decision to participate within their community and among those to whom such social relationships are important. Therefore, it is important that research explore whether participating within such social contexts, is a result of the norms of trust and reciprocity within social network relationships rather than a response to altruistic appeals. A data.  major criticism with Piliavin and Callero's work can be traced to their collection of  Much of their results are based on research done in the late seventies to mid eighties.  Although this may not influence some of the psychological findings or "regular" donor findings, it would not be able to take into account the historical changes that may influence non-donation. Blood donor research focusing on those who donate may not be able to explain reasons for nondonation. Blood donor research must examine the factors that influences non-donation, rather than extrapolating from donor research to explain non-donation.  For example, Piliavin and  Callero (1991), state "quite possibly, non-donors do not have a strong sense of moral responsibility to the community" (pg.36). This is an overly broad and general statement taken  18  from what is perceived to be a moral commitment of donors and thus generalized to assume that non-donors must be different. Research must be very careful not to assume that, although certain factors have been found to be influential to donors, they are automatically unimportant to those who do not donate. Healy argues that research must be careful not to be misled about the characteristic findings of donors, "many people with the characteristics of the typical donor are unlikely to be donors.  Many with the characteristics of the typical non-donor do in fact  donate"(Roberta and Wolkoff cited in Healy, 2000: 1635). We are therefore not able to make generalizations from research focused on donors to explain the decision process of non-donors but instead need to examine the social processes that influence decisions not to donate. Due to the  demographic shifts  in many communities in the  past  decade  (www.statscan.ca), these data would not be able to represent the influence that these population changes may have on donation. As demographic research has noted, there are strong differences in blood donation among various ethnic and racial groups (Boulware, 2002; Glynn et al 2002). This literature often makes reference to mistrust of the medical establishment, concerns about discrimination and issues related to perceptions of risk (Boulware, 2002; Peterson, 2002). As well, much of their data, particularly related to the blood donor identity role is based on the assumption that such a role is real and robust identity within one's community. Yet, without knowing the ethnic and racial makeup of the respondents, one could argue that such a role is somewhat limited to the dominant group due to their shared history of blood donation. Although the social psychological literature on donation has outlined influential factors for donation, explaining in part, why some donors give blood, it is unable to explain why so few people give in the first place. There is no explanation as to why neither the external nor internal motives studied are not able to explain the decision not to donate blood for this large percentage of the general population. Hence, this research is less successful in explaining non-donation or less than desirable rates of donation.  19  Blood donation literature, seeking to identify the psychological basis to motivation has, not surprisingly, consistently attributed most donation to individual altruism (Lightman, 1982; Glynn, 2002; Oswalt, 1975; 1977) and identity (Piliavin and Callero, 1990; 1991; Charng, 1988). Agreeing with Oswalt (1977), Piliavin and Callero (1991) argue that new research on donors and non-donors is unlikely to produce new information, since all research in the last twenty years has come up with the same findings. Yet, the demographic and social differences in donation rates point to something essentially social that is influencing the decision to give blood. Thus, it seems evident that in order to fully understand donation, research must focus on the social context in which this decision occurs.  Demographic analysis of donation  Much of the blood donor literature examines the demographic compositions of blood donors, trying to identify factors that influence differences in donation.  Healy argues that  characteristics of donors are not able to explain donation because many non-donors have similar characteristics yet they continue not to donate blood. Thus, research must avoid simply looking at the personal characteristics of donors to explain blood donation (Healy, 2000). Therefore, demographic research offers insight to the social influences on donation. Demographic research on donors has identified that the model donor is a white male, between the ages of 33 and 40, is generally better educated and has higher occupational status than non-donors (Lightman, 1982; Piliavin and Callero, 1991; Oswalt, 1975; 1977; Leibrecht, et al., 1976). Although gender rates are more stable now than in the past women have higher rates of temporary deferral due to anemia, pregnancy and other health problems (Piliavin and Callero, 1991: 5). In the U.S. there has occurred a shift in the education, income and occupational level of donors due to the shift away from paid donation (Piliavin and Callero, 1991: 6). Research has highlighted the different blood donation patterns and possible motivations for blood donation by demographic groups (Glynn etal,, 2002; Wu, 2001; Boulware, 2002). 20  Glynn etal. (2002), found social pressure was a major influencing factor for young individuals and donors with high school or lower level of education. As well, men were more likely to respond to social pressure than women, and whites and Hispanics were more likely to report being encouraged by family or peers than black or Asian donors (p.220). Incentives such as gifts or raffles or in the form of testing for an infectious agent, was more influential for black and Hispanic donors. Black and Hispanic donors were also less likely than white donors to report donating because "it was the right thing to do" (p.220). Therefore, although Glynn et al. (2002) found that altruism and knowledge of blood need, were cited as primary reasons to donate, the data reveal that this actually varies according to demographic groups.  Thus, their research  indicates that external social processes are, in some cases, just as influential in blood donation as more individualist factors. Theses demographic differences point to the possibility of social influences such as culture and ethnicity, on decisions to donate. For example, research demonstrates that Caucasian donors are more likely to respond with altruistic reasons for donation than other ethnic groups. Although we are not yet able to understand the social processes that lead to this finding, it may suggest that reporting altruism as a motive for donation is less a real motive than a representation of a cultural view of donation that is not held by other groups (Boulware, 2002). Piliavin and Callero (1991) argue that demographic differences are more likely to result from differential targeting or recruitment than from any real differences in motivation by people of different groups.  It is difficult to dispute this statement, yet a review of donor rates  demonstrates that social demographics ,such as community membership, ethnicity, education and gender (Glynn, 2002; Boulware, 2002; Ipsos-Reid, 2000) are important to explore as they give evidence to the social influences in decision to donate blood.  21  Social Structural analysis of donation  Blood donation literature has paid scant attention to the social structural influences on donation. One of the first texts to examine the social basis to donation is Titmuss' (1970) classic, 772e  Gift Relationship. That study examined the social organization of the blood supply in  England and the United States. It compared the commercial, market-driven system then existing in the US with the voluntary system in England. It sought to show that a system based on altruism and humanitarianism, offers no incentives to deceive because there are no personal benefits to be gained and, thus, results in a safer and more efficient system. In a market-driven system, people have incentives to lie about their health and thus are more likely to contaminate the blood supply. In recent years, criticism has been leveled against Titmuss' research, and it now seems to be widely acknowledged that his thesis, while provocative, was inadequately supported (Cooper and Culyer, 1968; Arrow, 1972; Sapolsky, Harvey and Finkelstein, 1977; Healy, 1999; Rappaport and Maggs, 2002). This criticism has been focused on both his methods as well as his economic analysis of a voluntary vs. market led system. Criticism concerning his methodology tends to focus upon the analysis of his data, generally stating that his methods and data are not able to support his final arguments. Rappaport and Maggs (2002), argue that his data are flawed and un-trustworthy due to errors in his methodology; particulary the lack of information about questionnaire design, discrepancies in data collection, confusion over questions 4 and 5 (the only questions related to motivation), and lack of detailed information about how the data were analyzed (p. 500). A second major criticism of Titmuss' work is aimed at his analysis of a voluntary versus market led blood system (Cooper and Culver, 1968; Arrow, 1972; Healy 1999, 2000). Healy (1999) re-evaluates many of Titmuss' conclusions by comparing the response to the AIDS, epidemic of voluntary whole-blood banks and commercial plasma companies. He comes to more subtle conclusions than Titmuss, based on careful analyses of the particular institutional and  22  social ties of commercial and voluntary blood collection groups. He argues that Titmuss' finding that donated blood was of higher quality was a contingent consequence of the particular health risk in transfusions at the time (Hepatitis). Whereas, in the case of AIDS voluntary donors (who were disproportionately male homosexuals) tended to provide lower quality blood than their paid counterparts. More recently, Healy (2000; 2002) has challenged the idea that individual altruism and the altruistic personality explain donation. He argues that most research on blood donation seeks to identify the demographic and psychological characteristics of donors (Piliavin and Callero, 1990; 1991; Boulware, 2002; Glynn, 2002; Ying, 2001; Ipsos-Reid, 2001), which leads to the idea that there exist a "special class" of people who give blood and a class of people that does not (Healy, 2002).  Instead, his research demonstrates how the social structural context in which  blood donation occurs, "provides incentives, opportunities and constraints" (ibid: 1634). Comparing donation systems within the European Union (EU), he identifies differences in donation rates and relates these differences to the three collection regimes; state-run, Red Cross and blood banking. Healy poses a number of hypotheses to test the influence of demographic indicators such as: gender, education and income; impact of various institutions; and the relationship between participation in volunteering and blood donation. The data for his study derive from the 1994 Eurobarometer survey, which asked numerous question about blood and plasma donation. To examine these data he runs a series of logistic regression models for each country, modeling donation versus non-donation. His findings reveal that state run systems have a larger than average donor base but are not able to retain this base as well as Red Cross systems whose base is smaller but contains more "regular" donors. Compared to state run and Red Cross systems, countries with blood banking systems show the widest variation in donation rates.  23  Healy's research also identifies how regimes influence not only donation rates but the meanings attributed to donation. For example, under state-run systems, blood donation is an activity that people will do once or twice but not continue throughout their lifetime, whereas Red Cross systems recruit a smaller but more "committed" donor group made up of individuals that are more religious in nature and participate in more voluntary activities.  Thus, in countries with  Red Cross regimes, the relationship between altruism and blood donation exists due to the meanings proscribed by the collection agency, rather than a result of the characteristics of individual donors (Healy, 2000). This is a very intriguing finding in that to some extent it contradicts social psychological research on blood donor motivation. Healy argues that "it's [blood] symbolic resonance - an anonymous gift of life to an unknown recipient- only makes it more likely to be mentioned in the same breath as altruism" (2000: 1633). As a result, it is "not the act itself or the individual qualities of donors" that are necessarily altruistic, rather the altruistic meanings attributed to donation are the result of the blood collection agency (Healy, 2000: 1654). This finding may help to explain why much of the blood donor research has found that donors usually cite altruistic reasons for donation (Piliavin and Callero, 1991, 1990; Lightman, 1981; Glynn et al, 2002 ). This type of structural analysis has not been completed in the U.S. or Canada, but leaves one to hypothesize that reasons cited by donors for giving blood must be related to the meanings attributed to such an act. As Piliavin and Callero have shown, for some donors, altruism may be given as a "form of rationalization" rather than being an actual motivation. The existence of such a rationalization must be tied to the meanings given to donation within most voluntary blood donation agencies.  With such a strong relationship attributed  between altruism and blood donation, it is not surprising that most donors cite altruism to explain their participation. Healy's work provides valuable insight into the institutional and structural influences on donation rates and the meanings attributed to this act by collection agencies. Although Canada  24  has one system that is responsible for collection of blood, it is fundamental to understand how the differing collection practices of that agency provide, as Healy states, "incentives and constraints to donation" (p. 1634).  If, as Healy suggests, collection regimes produce different donor  population, it will be important to determine how this occurs and identify potential changes that may facilitate a broader donor population. An important aspect of Healy research was the examination of the relationship between volunteering and blood donation. Much of the blood donation literature has attempted to examine the relationship between volunteering and donating blood, yet the results have been conflicting. Some research has indicated the blood donors have higher rates of volunteering than non-donors (Boe,  1977; Weisenthal and Emmot, 1979; Putnam, 2000).  Putnam (2000), found that a  relationship between these two activities did indeed exist. He argues that in order to predict participation in blood donation one needs to know how active a person is within their community and social networks. Yet, other research has found no correlation between volunteering and donation (Healy, 2000; Piliavin and Callero, 1987, 1991).  Healy (2000) hypothesized that  countries with high rates of volunteering will have high rates of blood donation. His results demonstrate that no correlation exists between these two activities therefore suggesting that blood donation is not the same type of activity as regular volunteering. He argues that if donation was a regular voluntary activity, then blood donation rates should line up with volunteer rates and research has shown that there are large differences in the changing rates of these two activities. Since blood donation is reliant upon voluntary donors, research must attempt to understand why it is a unique type of voluntary activity. It may be, as Piliavin and Callero (1987) found, that blood donation is a substitute for other types of volunteering (p. 9). Or, the difference may be due to the perceived risks associated with giving blood that have been identified in the literature (Boulware, 2002; Lo Bello, 1990). Very little research has examined the role that community membership plays on decision to donate.  The research that exists has indicated the importance of community need as the 25  primary motivating factor in blood donation (Foss, 1983; Leibrecht et al., 1976; Beagley et a l , 1978). Foss (1983), argues that social psychological research has failed to take into account factors that influence donation at the community and organizational level. His research examined the effects of community norms on donation. Foss (1983), studied two universities that had substantially different donation rates and demonstrated that individuals who perceived a greater degree of community support for donation were more likely to have donated in the past year. The community with higher donation rates also had higher rates of perceived social norms supporting blood donation. This result is supported by research completed by Piliavin and Libby (1986), whose study of seventeen Wisconsin communities, found that the strength of community norms regarding donation correlated with higher yield blood drives. Although the social structural research on donation is limited, what does exist suggests that blood donation can best be understood through an examination of the social context in which donation occurs. It seems evident that research must further explore how the institutional and social contexts influence donation rates, influence the meaning attributed to the act, provide opportunities to donate for some and limit access and motivation to donation for others. By categorizing donation as an act of altruism, blood collection agencies may be unable to access potential donors that would respond more readily through community-based appeals rather than appeals aimed at an individual level.  Summary The blood donation literature has highlighted valuable findings that help to explain motivations to donate for some individuals. The work of Piliavin and Callero (1991), provide insight to the relationship between altruism and blood donation, through their examination of repeat donation and the development of a blood donor identity role. This literature has identified that many donors do indeed cite altruism and humanitarian reasons for donation (Piliavin and Callero, 1991; Glynn et al, 2002; Lightman, 1981). As well, they discuss the importance of 26  situating these individual motivations within the context of a larger framework including structure, time and situation. Yet, their explanations of such behaviour tend to focus on the individual nature of donation rather than explore the social nature of this act. Although this work has provided a fundamental basis to the body of literature on blood donation, there continue to exist some gaps in understanding the multi-dimensional influences to blood donation.  The demographic literature has demonstrated that there is indeed something  social that influences the decision to give blood.  Donation rates vary by age, gender,  race/ethnicity, socio-economic status, education and community or geographic local (Glynn et al, 2002; Boulware, 2002, Foss, 1983; CBS, 2002). If, as the psychological literature has suggested, blood donation is related to the internalized motivations of altruism, one would have to believe that these demographic differences are somehow related to levels of altruism within these populations. Yet, as Healy has argued, it is hard to see how differences in donation rates are purely the result of individual altruism. Instead, research must pay attention to the inherently social nature of such an act, and the influence of social structural arrangements on decision to donate. Therefore, while not denying that altruism plays an important role in the decision to donate blood, the literature suggests that one must understand how different social contexts influence this decision as well as provide meaning to such behaviour.  If one understands  donation as an inherently social act, then donating as a member of a social network or community may help to sustain participation for those to whom these relationships are important. Therefore, donation within such social contexts may be the result of relationships of trust and reciprocity rather than simply altruism.  27  Chapter 3: Non-donation, Deferral and Lapsed Donors Research on Non-donation  Much of the research on blood donation has been focused on those individuals who have donated blood, at least once. There is scant research on the social processes related to nondonation and the multitude of factors that influence decisions not to donate. By studying nondonors, one may identify factors that are unaccounted for in the existing blood donation research. Much of the literature separates research on donors and non-donors, therefore, in order to more clearly examine the factors that influence non-donation I have keep the review of this literature separate. The literature identifies that non-donation is related to fear, belief in medical ineligibility, apathy,  inconvenience and fear of HTV (Piliavin, 1991; Oswalt, 1975, 1977; Condie, 1976;  Leibrecht, 1976; LoBello, 1990; Ipsos-Reid, 2001). To date, most of the literature on nondonation has been mostly descriptive rather than explanatory. It's purpose has been to identify factors that influence this decision, yet it has done so without an examination of the social context in which this decision is made and in the absence of a theoretical framework with which to provide explanation. Research on non-donation is essential, for it will provide researchers with a more broad understanding of under-explored motivations and barriers to donation. Fear and concerns of safety are two of the major reasons given for non-donation (Piliavin and Callero, 1991; LoBello, 1990, Ipsos-Reid, 2001; Farrell, 2001; 2002). In the research, fear is generally said to result from fear of needles, pain, sight of blood and possible effects such as weakness and dizziness (Boe, 1977; LoBello, 1990, Piliavin and Callero, 1991; Leibrecht et al., 1976). One problem that arises from this literature is the vague way in which the concept of fear is utilized. As shown, fear is correctly used to identify tangible feelings such as a fear of needles, but, often it is unclear as to whether fear is used to encompass issues of safety and risk or if it is understood as a distinct concept. An example of this can be seen in the opinion polls conducted for the CBS which identify "safety', as one of the major barriers to donation.  28  Within this poll, safety is not defined or properly identified, therefore we are unable to determine what constitutes safety for these Canadian respondents (Ipsos-Reid, 2001). This is fundamental to the creation of strategies targeted to increase donation. Concerns related to risk and safety, such as HTV infection, Hepatitis C and West Nile would need to be addressed very differently than those concerns related to fear of needles or pain. Due to the recent history of the tainted blood scandal, and the emergence of new, potentially dangerous pathogens, it is important to understand how the perception of risk, or understandings of risk possibility contribute to a person's decision not to donate blood. Current research has shown risk of HTV infection remains a factor in the decision-making processes of non-donors (Farrell, 2002, 2001; LoBello, 1990). Therefore, it is important that forthcoming research clearly identify and define these distinct concepts. If indeed fear of HTV risk continues to inhibit donation, collection agencies would need to address this perception of risk held by the public. One aspect of non-donation that needs further clarification, is whether the decision to donate is an active or passive decision.  Research needs to explore the difference between  deciding to be a non-donor and simply not making time to donate blood.  Research has shown  that a primary reason for non-donation is that people were not asked to give (Drake, 1978; Drake, Finkelstein and Sopolsky, 1982). This research has stated that non-donors gave their highest ratings to "nobody asked me personally" (Drake, Finkelstein and Sopolsky, 1982). Therefore, these authors suggest that rather than making a conscious decision not to donate they had not been asked and therefore did not consider it. Condie et al., (1976), adds an important dimension to this research. This study found that that mass media appeals from blood centers did not count as actually having been asked (Condie et al., 1976). Respondents in this study felt that only personal contact from a blood collection agency constituted being asked to give. This finding is of great importance to the collection of blood in Canada. The majority of appeals for new donors occur through the use of television advertisements. The CBS has recently 29  aired new media appeals, using social responsibility and altruism to garner new donors. While these appeals may be related to the 9% increase in whole blood collection in 2002/03 as compared to 2000/01, donor statistics show that the new donor rate decreased by 9% in 20022003 when compared to the donor rates in 2001-2002 (CBS data warehouse, 2003: 3). Therefore, the impact that such appeals have on overall donor rates continues to be unclear. Since the Condie et al. study was done in 1976, it is possible that time has changed the way in which we view such advertisements and agencies may need to find new ways to target potential donors. Although research generally treats non-donation as a passive decision, there are some examples in which this is not the case. Within intense social environments such as blood drives at schools or work places with great social pressure, non-donors made a conscious decision not to give (Piliavin and Callero, 1991; Drake, Finkelstein and Sopolsky, 1982). For example, about 20% of non-donors in the general public have made a conscious decision not to donate as compared to 74% of non-donors in "intense environments such as blood drives at universities and work places" (Drake, Finkelstein and Sopolsky, 1982). Thus, within these environments, only those who are strongly opposed to donating remain non-donors.  Other than identifying factors  such as fear, this research has not examined other, possibly more explanatory influences on this decision. It may be that non-donation within these environments is the result of broader issues of risk consciousness and risk perception rather than simply fear. As the concept of fear is not well explored, one is left without understanding what aspects of blood donation promote fear in these individuals.  As well, the environment is which such drives are conducted may be impeding  donation. Since an increase in new donors will have to occur from the current non-donating population, it is important to understand the social processes that influence the decision not to donate.  30  Impact of deferral on continued donation  When looking at non-donation it is fundamental to explore the literature on deferral. Deferral from donation can occur either permanently or temporarily. A permanent deferral is due to "high risk" behaviours, including intervenous drug use, prostitution, male homosexuality and place of origin. Temporary deferral is usually the result of illness such as cold/flu, medication use, hemoglobin levels and tattoo or piercing (www.bloodservices.ca). Research has shown that temporary deferral has a negative effect on return donation. Hence, when a person has been deferred, even temporarily, their chance of returning is quite slim (Piliavin and Callero, 1991; Halperin, 1998; Beel, 1999). With the recent implementation of safety policies, including an expansion of exclusion criteria to safeguard against pathogens such as vCJD and West Nile Virus, it will be important to have those donors that have been temporarily deferred, return to donate when eligible to do so. This will help to increase the donor base and retain much needed donors. Along with agency deferral, there also exists the possibility that individuals are selfdeferring, believing they are medically ineligible. Although the research on this activity is quite scant, as well as dated, what does exist indicates that self-deferral occurs. One study by Leibrecht (1976), found that 33% of non-donors did not donate believing they would be disqualified due to medical ineligibility (p. 187). As stated earlier, the CBS has had to introduce new exclusionary criteria in order to ensure safety from various pathogens. It is important to know whether nondonors are self-excluding, believing they are ineligible to donate due to their inadequate understanding of these policies. There has been much media attention paid to these new policies therefore, we need to understand if non-donors are making the decision not to donate, believing themselves ineligible, rather than actually being deferred from the blood donor clinics? If this is occurring, the CBS will need to determine how to better communicate these policies to the public so as to not discourage potential donors from donating.  There is also the possibility that  31  individuals who are self-deferring are doing so to avoid donating, rather than because they truly believe they are ineligible.  Lapsed donors Another important area of study with regard to non-donation, is the occurrence of lapsed donors. These are donors who have given once and not returned to donate. There has been very little research conducted on reasons for lapsed donation. Normally, within the blood donation research, donors who have given once and not returned are either subsumed under the category of donor or considered non-donors. Yet, they are unique to both donation and non-donation and therefore require study. Research indicates that lapsed donors are important to target as they have lower incidence of HTV, Hepatitis C and B as compared to new donors (Schreiber et al, 2003). As well, they may provide insight into motivations and barriers not yet understood. It would be important to understand what initially motivated them to give blood, and yet could not sustain their participation. Data collected by the CBS indicate that each year they lose over 30% of their active donors (CBS, data warehouse, 2003: 5), with 82% of donors lapsing never returning to donate (CBS, data warehouse, 2003: 16). Research indicates that not returning to donate is related to issues such as negative first donation experience (reactions such as fainting and dizziness); poor experience with donation staff; and giving due to social pressure (Piliavin and Callero, 1991; Schreiber, 2003; Charng and Piliavin, 1988). While important, research on non-donors has not explored such factors in depth and has done so in the absence of a theoretical framework. Therefore,findingsare given little explanatory power towards an understanding of non-donation. Lapsed donors are an important area of study as they may provide insight to both factors that influence donation as well as barriers to continued donation. Understanding how influences such as the context in which they gave, their initial motivation and their experience of the  32  donation process will contribute to a better understanding of changes that may facilitate continued donation and strategies to decrease the occurrence of lapsed donation.  Summary While much of this research has tried to highlight the differences between donors and non-donors, some has shown that there are no significant differences in these populations (Condie et al, 1976; Piliavin and Callero, 1991; Healy 2000; Roberts and Wolkoff, 1988). In their study, Condie et al (1976), found that altruism and social responsibility are not significant in discriminating donors from non-donors.  Similar results were demonstrated by Piliavin and  Callero (1991), in a study of 296 donors and dropouts, which found very few differences in significant variables to explain continued donation. Generally, they found that the differences between donors and dropouts are not natural or inherent characteristics the donors bring to the donation setting. Rather, they are " attitudes, feelings and expectations, that develop as a result of repeated donation experiences" (p. 132). Though these findings are valuable, they do little to explain non-donation and lapsed donation. If there are no inherent differences between donors and non-donors, then it seems reasonable that the barriers to donation must rest in issues of safety and risk, as identified by the literature, or factors that have not been explored by the current research. While the existing research on non-donation has identified factors and possible reasons that affect decisions to donate blood, they may not reflect the social realities and situations in which these decisions are made. Research must explore how perceptions of safety and risk influence a person's decision to donate so one is able to understand whether these identified barriers to non-donation are the result of poor communication strategies on the part of CBS or are a form of rationalization due to people's lack of desire to give blood? Given that the category of non-donation includes those who have never given, those who have attempted to give and been deferred as well as those who have given once and not returned,  33  the value of this research is quite broad. Such an examination is fundamental in that it may provide a unique understanding of both motivations to donate as well as barriers that impede blood donation. The knowledge derived from this research would assist in the development of strategies to address current barriers as well as potentially increase the donor pool.  34  Chapter 4; Alternative Perspectives on Blood Donation  An examination of the existing blood donation literature highlights flaws inherent in the research and areas that require further examination. One main aspect of the literature that has been under-explored relates to the social structural factors that mediate the decision to donate blood.  The social psychological research on donation provides valuable understanding of some  individual motivations to donate for a small group of "committed", regular donors, but overall lacks the ability to explain the motivations of those who donate less regularly, and pays little attention to the factors related to non-donation. The focus of such research has been to explain the internal motivations that sustain long-term donation by arguing that intrinsic motivations related to altruism are the main explanatory factors for blood donation. Yet, a review of the research has shown, that although motivations such as altruism may be able to explain some donation, social structural factors remain profoundly influential to the decision to donate (Piliavin and Callero, 1991; Glynn, 2002). Therefore, a focus on internal and self-based motivations are not able to provide an understanding of the influential nature of social structural factors as well as obscure the importance of the social influences in decision to donate blood. The focus of most blood donor research has been to explain donation as the result of an altruistic identity or blood donor identity role. One problem with such research can be found in the assumption of altruism as an individual or self-based motivation, which leaves the explanation for blood donation somewhat vague and theoretically problematic.  From a sociological  perspective it is fundamental that a discussion of altruistic behaviour must be situated within the social world rather than discussed solely as the product of individual behaviour. That acts of altruism are inherently social in nature and thus, describing altruism as something that derives from the self is somewhat limiting. There is a need to understand how the social context in which such actions are made, influence not only the decision to donate or not, but also the meanings attached to participation.  35  Piliavin and Callero (1991)  rely on five theoretical perspectives: Opponent Process  Theory; Attribution/ Self-Perception Theory; Becker's Model of Commitment; Identity Theory and Theory of Reasoned Action (Piliavin & Callero, 1991: 199). As well, they also identify four mutually dependent dimensions: self; situation; social structure; and time and argue that future research should examine interdependencies across these four categories. Although their findings are examined within the framework of each theory, the decision to donate is ultimately seen as resulting from individual difference and self identity rather than understanding the role that social commitment or social network relationships play in this decision making process. Thus, it seems important to examine the donation process from an alternate perspective, particularly one that is able to explain the influential nature of social structural factors. Both the demographic and structural research on blood donation gives evidence that something social is behind decisions to donate blood.  Although not explanatory, the  demographic literature provides a snapshot of the influence of social factors in donation rates including ethnicity, socio-economic status, gender, race and education (Glynn, 2002; Boulware, 2002; CBS, 2002, 2003). The structural research on blood donation expands on such work by demonstrating the importance of understanding how social structural factors influence donation rates as well as the meaning attributed to donation (Healy, 2000; Foss, 1983). Although the contribution of such work to the body of literature is important, some of the research lacks explanatory power. In Foss' (1983), study, there is no description of how communities with different donation rates vary, thus we are unable to determine what aspects of community are influential with respect to donation.  Therefore, donation differences in this context are left  without an explanation for this occurrence. In order to explore the stated research questions and examine the social structural influences of donation I will rely on the theoretical literature related to social capital, trust and risk. This literature will be examined in line with current research and current blood collection practices in order to examine both donation and non-donation within a social context.  36  Social Capital The relationship between social capital and economic and social well being has been the subject of academic analysis and research in the past decade (Putnam, 2000; Coleman, 1988; Kawachi, 1997). The central idea of social capital is that the networks of relationship and reciprocity that people develop in society have value with regard to other aspects of social life. The essence of the social capital perspective rests in the way in which it relates the presence of such social networks to other aspects of societal well-being. The basic proposition underlying this research is that, by forming social networks for their individual and collective purposes, individuals develop 'social good' that goes beyond their individual and collective actions (Putnam, 2000; Lin, 2001). Hence, social capital develops through such network relationships primarily in the patterns of trust and reciprocity that develop, the outcomes of which are various forms of collective action. Thus, when people are involved in social networks and relationships that are meaningful and in which trust is inherent, they are motivated to maintain these ties and therefore act in the interest of the group, rather than just their individual interest. According to Putnam (1993; 2000), it is the norm of generalized reciprocity that fuels the social trust that is the foundation to social network relationships. This is the trust possessed by community members that their short-term altruistic actions that contribute to others' welfare, will be rewarded at some point in the future. Therefore, "each individual who act in a system of reciprocity is usually characterized by a combination of what one might call short-term altruism and long-term interest: I help you out now in the (possibly vague, uncertain, and uncalculating) expectation that you will help me out in the future" (Putnam; 2000: 134). Hence, within a social capital framework, the decision to participate in blood donation may result more from issues of trust and reciprocity developed within these social network relationships, than individual altruism. Therefore, within such social contexts, it may hot necessarily be the decision to give blood that is made per se, but the decision to act in a manner that maintains the interests of the  37  group. Participating within this social context may provide both the meaning and motivation to donate blood, both of which may be linked to one's social network relationships. One of the major flaws of the blood donor research can be traced to a lack of specificity in the terms used to describe and explain motives. Throughout the social psychological literature the concepts of social pressure and other's expectations are examined as expressions of external motivation yet, obligation and ties to community are expressed as internal motives (Piliavin and Callero, 1991).  The literature does not clarify how the factors associated with external and  internal motivation are distinct.  Using a social capital framework provides a context in which  such research must question whether for some individuals; social pressure and other's expectations may present itself as obligation to one's social network relationships within their community. Therefore, without an understanding of how these two factors are conceptually distinct, an analysis of the data based upon these factors seems insufficient. The social psychological literature has not effectively addressed the role of community and social network relationships founded upon trust and reciprocity, as influential factors in the decision to donate blood. As research has indicated, blood collected at mobile sites, particularly in small communities, does so by mobilizing community members to donate based on their ties to their social group or community, rather than as an individual (www.bloodservices.ca; Piliavin and Callero, 1991; Surgenor and Cerveny, 1978). These blood drives have been, and continue to be, extremely successful, which seems to indicate that the concepts of extrinsic and intrinsic motives, and the variables used to express them, are insufficient explanations of donation within these social contexts. Using a social capital perspective to study blood donation focuses on how the networks in which individuals belong, provides the framework, which guides their blood donation behaviour. It examines the way in which such social network relationships become significant influences on patterns of blood donation behaviour, and how these are linked to broader issues related to understanding trust and reciprocity as well as understandings of risk.  38  One difficulty that arises with such an approach is that the norms of trust and reciprocity associated with social capital are difficult to distinguish from altruism. This is not to suggest that these concepts are not related, yet, by using a social capital perspective, it seems imperative to disentangle the norms of altruism from those of trust and reciprocity within social networks. Such work has been attempted previously, mostly within the realm of economics using economic experiments and trust games ( Gneezy, Guth and Verboven, 2000; Carter and Castillo, 2002). Carter and Castillo (2002), used a multi-stage experimental design that allowed them to develop intra-personal comparison measures, thus allowing them to distinguish trust and reciprocity from altruistic caring for others.  The results of their data reveal that while related, trust and  reciprocity are clearly different from altruism. To date, blood research has paid little attention to the norms of trust and reciprocity as explanation for participation in blood donation. One reason for this may rest in the meanings attributed to blood donation within a voluntary system. In such systems, the desire to attribute blood donation to altruism results in a reluctance to understand other influences to participate.  The reluctance to see blood donation as  influenced by other motives results in an unwillingness to introduce certain strategies that may increase donation. One example of this can be seen in the firm stance taken by the CBS against the use of incentives (Webb, 2002). Such incentives are believed to recruit the wrong type of donors, mainly those who are not giving for altruistic reasons, and put the blood system at risk (Webb, 2002; Piliavin and Callero, 1991). This is not to suggest that incentives are necessarily the best strategy for recruitment, instead, this example helps to highlight the way in which the meaning given to donation is maintained through structural influences.  This argument is supported by Healy (2000), whose research  39  demonstrates the influence that blood collection organizations have on the meaning given to donation. Social Capital and Community The social capital perspective provides a framework in which to view differences in donation rates, particularly at the community or group level. Research has indicated that donation rates vary by community and geographic local (Glynn, 2002; Foss, 1983; Piliavin and Callero, 1991). Although some of these differences are a result of the availability of collection facilities this alone is not able to explain donation differences.  For example, within Vancouver, blood  clinics are held six days per week as compared to such areas as Surrey, which hold clinics twice weekly. Yet, Surrey is able to recruit a fairly high proportion of donors; Vancouver 3.3%; Surrey 3.2% (CBS, 2002). These differences seem to indicate that accessibility is not the only factor that determines donation rates. Along with accessibility, communities vary in their levels of social capital, therefore, it is important to explore how processes of social capital such as trust, reciprocity and network ties, influence both donation and non-donation within these contexts. A review of collection practices in both Canada and the US, highlight the importance of community membership for blood donation. The Canadian Blood Service has designed specific programs to target members of various social networks or communities in order to foster blood donation. Much of the collection of blood, outside of fixed sites, is achieved through communitybased programs linking blood donation with community membership, including: country of origin, religion, ethnicity, work environment and school.  One example of this can be seen in  their Life Link program designed to attract businesses, corporations, schools and associations to foster donation among their members or employees. Participating businesses are expected to educate their employees on the importance of donation and the staff are given time off to donate with one another. Blood donation within these contexts is linked to group identity, work relationships and values of participating members (www.bloodservices.ca).  Preliminary data  40  collected on donation frequency in the Life Link program demonstrates that group donation has higher donation frequency than single donors. Within the Life Link program 30% of those involved donate three to four times per year as compared to 15% of those donating as single donors. As well, 35% of those involved in such group donation programs give twice per year as compared to 20% of single donors (CBS, 2003). Although research on motivation has not been completed on such a project, these numbers suggest that donations by group or social networks are able to sustain higher rates of participation than are single donation strategies. In order to motivate blood donation within such networks, many of the mobile clinics link donation to specific group values or shared belief systems. A recent blood drive at Canadian air force bases highlights the use of such strategies. Family members and soldiers were asked to give blood in order to pay tribute to Canada's military personal both present and past (www.bloodservices.ca). Thus, the use of community and shared belief helps to foster donation within this segment of the population. The donor act is given personal meaning to individuals as a member of a larger community with shared experience and values. The most current opinion poll completed by Ipsos-Reid for the CBS found that 39% of those interviewed cited "I like the social aspects of blood donation" as motivation to donate (2003:  10).  When asked what was most likely to influence the decision to donate, 64%  responded "advertisement from someone in their community that needed blood" , and 41% said that "an advertisement from a doctor within their community" would motivate them to give blood (2003: 36). These findings seem to indicate that rather than being motivated by altruism that responds to a general need, some individuals would respond more positively from appeals that are more personal in nature and more meaningful to them as a member of a social network within a community. These examples further strengthen the research findings, which point to the importance of community and social network ties to participation in blood donation (Glynn, 2002; Foss, 1983). The use of a social capital perspective will provide a framework by which to explore the  41  influence of social networks on decisions to donate blood. Yet, as suggested, it is important that such research pay attention not only to those who already donate, but also try to understand what barriers exist to non-donation. If some communities are able to gamer support for donation, whereas other are not, what differences, other than accessibility, help to explain donation rate differences across various communities? Generally, non-donation is seen as a form of non-decision, thus individuals do not actively decide not to donate, but rather, just do not donate. The literature suggests that most of non-donation results from not having been asked to give (Drake, Finkelstein and Sopolsky, 1982; Condie, 1979). Although this may provide explanation for some non-donation, the literature also points to specific collection drives in which a small percentage of non-donors actively make the decision not to donate blood (Drake, Finkelstein, and Sopolsky, 1982). Within such "intense collection environments" non-donors have made a conscious decision not to give.  In their  opinion poll of the general public, Ipsos-Reid found that 45% of those interviesed stated they had "no plans to donate but might in the future" , whereas 25% said "they will never donate" (2003: 33).  Thus, research will need to explore the continuum of non-donation, from those potential  donors who feel they have not been asked to give, to those who intend to give and finally, to individuals who have made a decision not to give blood. This may be particularly relevant in community settings. Thus, this type of analysis may help to identify how processes of social capital formation, such as social network ties, trust and levels of reciprocity, could be utilized to foster donation among people within these social contexts.  Ethnicity and blood donation  Research indicates that there exist ethnic differences in donation rates (Glynn, 2002; Boulware, 2002; Wu, 2001).  The latest Canadian census revealed that 13.4% of Canada's  population belongs to a visible minority (www.statscan.ca).  In BC, the proportion of visible  minorities is 37% and in areas such as Richmond and Surrey the numbers are even higher with  42  60% and 37% respectively (www.statscan.ca). This demographic provides a challenge to blood collection, as collection strategies are needed that would relate to the distinctive needs and possible barriers that exist in these communities. While the average donor is a white male, in his thirties (Piliavin and Callero, 1991; Healy 2000; Glynn, 2002), the shift in demographic makeup of the Canadian population suggests that new strategies to recruit donors from other social backgrounds are needed in order to meet blood shortage requirements. As well, different ethnic groups provide the opportunity to obtain rare blood types (www.Bloodbook.com) that are often located within these populations and meet the blood needs of specific groups. For example, in the US there exists the need to identify African  American  donor  matches  (http://www.stlouischildrens.org).  for  children  with  sickle  cell  diseases  Thus, the targeting of specific ethnic groups is not only  important to address overall blood shortages, but provide specific blood types for members of those groups. Although relatively few, the CBS has begun to use existing programs such a Life Link and Community Partners to establish programs that target specific ethnic and religious communities in the Lower Mainland. One example of such a program is the blood donation camps organized by the Public Awareness and Welfare Society (PAWS) and the CBS. This program was established to specifically target the Sikh population in the lower mainland to donate blood. To gamer support for donation these camps are held in honour of the victims of the massacre of thousands of Sikhs in India in 1984. The result of such a camp has been impressive, with 350 people showing up to give blood while the camp was only able to sustain 242. Each year the success of these camps has been tremendous  (www.Sikhnet.com). This seems to  suggest that linking donation to larger issues important to an ethnic community helps to stimulate the blood donation process.  Thus, for some communities, individual appeals may be less  effective that strategies targeting the community as a whole.  43  Most of the donation research has examined donors and non-donors from predominantly mainstream populations. While research has indicated differential donation rates among ethnic groups, it has not explored what motivates ethnic minorities to donate and what barriers to donation may exist in these communities. Previously published literature suggests that religious belief and cultural affiliation influence willingness to donate blood (Holroyd and Moassiotis, 2000; Webb, 2000; Boulware, 2002; McNamara, 1999). In a report completed for the CBS, Webb (2002) examines the donation rates from Chinese populations in Vancouver.  His  examination suggests that, for Chinese individuals, fear of donating blood may result from traditional beliefs about chi (life force), whichflowsfromone's blood. Therefore, the donation of blood may result in weakness and make one prone to illness. As well, some literature has indicated that in the Chinese tradition, one's blood is inherited from one's mother and links a person to their family and history (Holroyd and Moassiotis, 2000). In their research Piliavin and Callero (1991) suggest that low donation rates among ethnic communities may be a function of the lack of outreach and targeted appeals by blood collection agencies.  They argue that the majority of appeals are targeted to mainstream populations of  which the agency has more experience and are not the result of ethnicity specifically (Piliavin and Callero, 1991). Although this may serve as one factor, it does not seem reasonable that agency alone can account for the entire difference in donation rates among ethnic communities. Instead, as research suggests, low blood donor participation among ethnic communities may be the result of mistrust and perceptions of risk and discrimination (Boulware, 2002; Peterson, 2002). As well, it is important to understand how social network formation, combined with cultural value systems may serve as power influences to donate within such communities. More research on the influence of ethnicity, cultural affiliation and religion are needed to determine how social capital influences within ethnic communities influence decisions to donate. Such research would be helpful in determining whether the current blood collection strategies, focused on appeals to individual's sense of altruism, are effective within ethnic communities or if  44  there is a need to develop culturally appropriate strategies, drawing upon the processes social capital residing in network relationships of trust and reciprocity.  Willingness to Trust and Perception of Risk Most of the research on blood donation has focused on those individuals who have donated at least once. If studied at all, the research on non-donors tends to be descriptive rather than explanatory. Literature on non-donors has identified factors of time/inconvenience, fear, safety, mistrust and risk as explanation for non-donation (Piliavin and Callero, 1991; Boulware, 2002; Boe, 1977; Leibrecht et al., 1976; CBS, 2000; Farrell, 2002, 2001; LoBello, 1990). Often fear, risk and safety are used to represent similar issues such as: fear of needles; fear of medical procedures and fear or risk of HTV or other illness.  Two problems emerge from  such a generalized approach. First, without clarifying how the factors of fear and risk are distinct, research is unable to locate an explanation for non-donation. Therefore, research on non-donation must be careful to examine such issues delicately so as to identify both the relationship between the concept of fear and risk as well as their relationship to one another.  An individual's fear of  needles or medical procedures would be examined and targeted much differently than an individual who believes that donating may put them at risk of acquiring an illness such as HTV or vCJD. The second problem with such an approach is that reasons for non-donation are not placed within a theoretical framework and therefore, offer little explanatory power. In order to understand how people perceive and experience the issues of risk, fear and safety, research needs to incorporate a theoretical analysis that provides basis for explanation. It is not enough to simply state that fear and safety are factors in non-donation. The study of risk construction, risk perception and risk related behaviours is beaming increasingly well developed in western society and is of particular relevance to any sociological analysis of blood donation. This trend is encapsulated in what has become known as the 'risk  45  society' perspective (Beck, 1992; Giddens, 1991). This perspective emphasizes that there is a growing awareness by citizens of their exposure to risk, to the point that risk awareness is becoming an all-pervasive aspects of industrial society. Moreover, this risk awareness is coupled with a declining trust in scientific expertise, largely because some of the greatest environmental and health risks in society have either been caused by scientific and technical developments or by the failure of scientists to protect us from them. Indeed, past experience in Canada with the failures of the 'blood donation system' may, itself, have contributed to growing risk consciousness among the Canadian population. Trust is also fundamental to an examination of risk. An aspect of the 'risk society' includes a decline in trust in scientific expertise and expert knowledge (Beck, 1992; Giddens, 1990; Lupton, 1999).  Trust is used as a way to manage uncertainty in situations that are  perceived to be inherendy risky. As well, one of the key aspects of the  'social good' that  emerges from social capital formation is an enhanced level of trust. That is, frequent reciprocal interaction among people leads to a willingness to trust other individuals, and also generates a higher degree of trust in the bridging institutions of society (Coleman, 1988; Putnam 1993, 2000). In understanding the concept of risk one must be aware that the identification of risks and development of trust take place in specific socio-cultural and historical context in which we are located.  These social, political and cultural factors play an important role in how risk is  perceived.  Lupton (1999), argues that our knowledge and perceptions of risk contribute to our  understandings of the social communities within which we live and help to distinguish our selves from other social groups. An examination of perceptions of risk and level of trust are especially important in blood donor research that aims to understand social and demographic factors that influence participation. Research indicates that ethnicity and belief systems play an influential role in the decision to donate blood (Boulware, 2002; McNamara, 1999). In their study, Boulware et al. (2002), found that mistrust of hospitals and concerns about discrimination explained most of the  46  difference in willingness to donate blood for black and Hispanic non-donors compared to white donors. As well, they found that both Black and Hispanic donors were more willing to donate if the blood drives were held in community centers rather than hospitals or collection agencies (Boulware, 2002). Thus, fear and concerns of safety were not as prominent when donation occurred in a community setting. This finding suggests that for many, community membership and the corresponding relationships that exist within such settings, are fundamental for developing trust and mediating blood donation behaviour. Issues of risk, safety and fear have continually been associated with reasons for nondonation. Within Canada specifically, issues of safety have been identified as one of the main barriers to donation (Ipsos-Reid, 2001). Understanding perceptions of risk and levels of trust are fundamental to research on blood donor motivations. Recent failures to protect the blood supply from such pathogens as HTV, Hepatitis C, vCJD and West Nile virus may have resulted in an increased risk awareness of potential Canadian donors and a decrease of trust in the safety of the system.  Since the emergence of HTV and Hepatitis C, there has been a steady increase in  potential harms associated with the blood supply in Canada. Although little research has been done on the role that risk perception plays in donor motivations, it seems evident that such an examination is required to determine how this influences decision not to donate blood. As previously stated, although such concepts have been identified, 90% of Canadians have also been reported as believing the blood system is safe (Ipsos-Reid, 2001). Hence, if fear and risk are influencing the decision to donate research must explore how these concepts differ so as to address them appropriately. Understanding the existence of these factors would facilitate the development of communication strategies to address such issues. As well, research must explore whether donation within trusted community settings would assist in decreasing the influence of these factors. Or, whether such fears would exist as independent to the feelings of obligation and reciprocity to one's community.  47  Social Capital, Blood Donation and Voluntarism  Participation in voluntary activities is an important area of study for social capital theorists. Levels of voluntarism are related to the levels of social capital in a society. Therefore, communities with high levels of participation in voluntarism are also thought to have high levels of social capital. Thus, the greater the number of people that volunteer, the greater the integration and reciprocity among members, which translates into greater levels of social capital. Although a relationship between blood donation and participation in voluntary activity has not been established by the current research, it is fundamental to understand how the social processes for these activities differ.  According to the social capital literature, blood donation can be seen as a  primary example of volunteerism and, in that sense, can be taken as an indicator of the level of social capital in a society (Putnam, 2000). He argues, that the extent to which trust in institutions is nurtured and present in society is likely to be related to the willingness of the population to give blood.  However, the relationship between social capital and blood donation seems to be a  dialectic one. On the one hand, social capital and the trust that it generates likely contribute to enhanced levels of volunteerism, including enhanced levels of blood donation. At the same time, the donation of blood can be taken as a clear reflection of the level of trust and other attributes of social capital. Therefore, although blood donation involves many of the elements usually associated with social capital, it is important to understand how the social processes that lead people to participate in voluntary activities may be fundamentally different than those used to mediate participation in blood donation.  When one compares the national volunteering rates for  Canadians, we see that in 2000, 27% of the Canadian population volunteered time to a charitable or non-profit organization with the average annual number of hours contributed per volunteer being 162 (Stats Can, 2000: 31). These numbers seem to indicate that giving blood is a unique type of volunteer activity, thus brining one to ask what is unique about giving blood that may contribute to such low participation rates?  Thus, research needs to explore whether blood  48  donation is seen as a "normal" voluntary act, similar to giving time and money, or if there exist other considerations that make this activity entirely distinct. Hence, why does social capital formation operate in a unique manner for blood donation as compared to other types of voluntary activity? In communities with high levels of voluntarism and thus, social capital, is there a way to foster blood donation behaviour? When one compares the national volunteering rates for Canadians, we see that in 2000, 27% of the Canadian population volunteered time to a charitable or non-profit organization with the average annual number of hours contributed per volunteer being 162 (Stats Can, 2000: 31). These numbers seem to indicate that giving blood is a unique type of volunteer activity, thus brining one to ask, what is unique about giving blood that may contribute to such low participation rates? The final chapter will outline the gaps in current blood research, using a theoretical framework that incorporates social capital, trust and risk analysis to demonstrate how these perspectives provide a valuable framework in which to explore the social structural factors associated with decisions to donate.  Also included will be a general discussion that identifies  ways to study the identified research problems.  49  Chapter Five; Conclusions and Contributions to Future Knowledge  The existing blood donation literature provides valuable knowledge to understanding both the individual motivations to donate, as well as the role that social structural factors play in donation. The largest body of work has focused on the relationship between self concept, identity and altruism (Piliavin and Callero, 1987, 1988, 1991; Oswalt, 1977; Lightman, 1981; Elster, 1990; Glynn, 2002). Much of this research has been conducted by Piliavin and Callero (1991, 1988, 1987) whose purpose is to identify the transformation of identify that occurs through the process of repeat blood donation, ultimately resulting in the development of an "altruistic identity". A fundamental aspect in the development of such an identity is the shift from external to intrinsic motivations. The research attempts to demonstrate that first time donors, or early donors are more motivated by extrinsic motives, those being related to the social world such as social pressure and expectation. Then, as one continues donating their motives shift to intrinsic motives that are self based such as moral obligation and altruism. Although this research has provided fundamental knowledge to the body of literature on donation, there exist inherent problems in the design and analysis of such research. A social act such as blood donation, must pay attention to the social structural nature of such a decision, rather than seeing it as the sole product of an individual decision. Therefore, although most donors cite altruistic or humanitarian reasons for donation (Piliavin and Callero, 1991; Glynn et al, 2002; Lightman, 1981), such responses must be examined within the social context in which such decisions are made. Although Piliavin and Callero (1991), situate self variables within a larger context including structure, time and situation, their analysis is focused on determining self-based motivations to donate, thereby somewhat ignoring the role of the social. This can be seen in their examination of extrinsic and intrinsic motivations. They attempt to distinguish between extrinsic and intrinsic motives, seeing the former as social and the latter as self-based. From a sociological perspective such an analysis is problematic. Theoretically, it is difficult to accept that extrinsic motives such as social pressure and social expectation are distinct  50  from those used to describe intrinsic such as moral and social obligation. Both motivations are inherently social in nature and thus, seem to represent some form of external motivation. Therefore, although this work is valuable in providing an understanding of individual motivations to donate for a small percentage of donors, it is, however, less successful in explaining non-donation or less than desirable rates of donation.  As well, by focusing on  individual motivations to donate, little attention has been paid to understanding the social structural influences on donation. While not denying the role that altruism plays in decisions to donate blood, a review of the literature demonstrates the importance of understanding how social structural factors influence this decision. Both the demographic and structural research provides evidence to the importance of understanding the influence of social factors to donation.  The demographic  literature examines the composition of donors and non-donors, identifying differences in donation rates by community and geographic local, gender, education, socio-economic status and race or ethnicity (Glynn, et al, 2002; Boulware, 2002; Foss, 1983; CBS, 2002, 2003). These data seem to suggest, as Healy (2000) has argued, that if individual altruism were such a strong explanatory factor in decision to donate, rates of donation would not be as influenced by social context as appears to be the case. The structural literature has provided an analysis of the importance of understanding how the social structural context not only influences who donates, but also the meanings attributed to donation. In particular, Healy's (2000) research establishes an understanding as to the way in which blood collection agencies affect donor profiles and donation rates that are independent of the psychological qualities of individual donors. As well, Healy's work provides valuable insight to explain how collection agencies provide meaning to donation (2000). Therefore, although most donors cite altruism as explanation for donation, this may be the result of the meanings attributed to donation within a voluntary system, rather than explain actual motivation. This is an important area of study as most of the blood donation literature has focused on using altruism to  51  explain participation, when it seems evident that research needs to explore how altruism may be used as a socially acceptable explanation for decision to donate within voluntary blood systems. To date, research has focused almost exclusively on donors, with little attention paid to explanations for non-donation. Given that such a small percentage of the population donates, if one is interested in increasing donation rates, research must explore, within a theoretical framework, the reasons given for non-donation as well as the social barriers that prevent it. When research has attempted to study non-donors such work is done in isolation, outside of the context of donation. Instead, research must examine both donors and non-donors within a social context to determine how such processes provide motivation for some while simultaneously existing as barriers to others. Given that the category of non-donor includes those who have never given, those who have attempted to give and been deferred as well as lapsed donors, research on this group in particular, provides a chance to understand both motivation to donate as well as barriers that impede donation. The literature on non-donation has identified that barriers to participation include: fear of needles, distrust of medical establishment, belief in medical ineligibility, deferral, inconvenience, safety and risk (CBS, 2000; Ipsos-Reid, 2001; Piliavin and Callero, 1991; leibrecht, 1976; LoBello, 1990; Oswalkt, 1975, 1977; Condie, 1976). The majority of this research has been descriptive rather than explanatory, identifying factors that influence this decision but doing so in the absence of a theoretical framework with which to provide explanation. In order to be useful, research needs to explore whether the concepts of fear, safety and risk are conceptually related or distinct. The issues of fear, risk and safety are identified as barriers yet not explored to determine whether they are the product of the same thing or distinct. For example, when fear is identified as a barrier to donation, one is left unsure as to what aspect of donation produces fear in a potential donor. In order to identify strategies that would motivate donors to give, research must understand how perceptions of risk different for donors and nondonors.  52  The blood donation literature has demonstrated that altruism is sometimes used as a form of rationalization for giving blood rather than being a real motivation (Piliavin and Callero, 1991). A similar type of rationalization may be at work within explanations for non-donation. Consequently, research must explore whether responses of safety and time are being used as a verbal justification or socially accepted rationale for not giving blood and thus, indicating that the donation of blood is not seen as socially or personally important. A review of the participation rate in volunteering in Canada makes it difficult to accept that Canadians do not have enough time to donate blood. Currently, the CBS is asking Canadians to donate twice per year, with each donation taking approximately one hour.  Currently, the average annual number of hours  contributed per volunteer is 162. Therefore, it seems that Canadians make time for activities that are important to them and it seems that, and blood donation is not one of those activities. This project is premised upon the idea that blood donation research can be best understood through an examination of the social context in which the decision to participate occurs. In order to conceptualize the social context of donation and non-donation, this research utilizes three theoretical frameworks: social capital, trust and risk. Social capital analysis is well suited to such an examination, in that it provides a theoretical framework in which to view differences in donation rates, particularly at the community or group level.  It allows an examination of the extent that such social network  relationships, founded upon trust and reciprocity, become significant influences on patterns of blood donation behaviour. Therefore, rather than viewing decisions to donate as the product of individual altruism, one is able to see how such decisions, particularly within group-based donation, may be the result of relationships of trust and reciprocity. Therefore, the decision to participate in blood donation may be the result of a desire to act in a manner that maintains the interests of the group, thereby maintaining important social network relationships. A review of the demographic and structural literature points to importance of situating blood donation research within a social structural framework. New data emerging from the CBS 53  further supports this focus. A report completed for the CBS demonstrates that, rather than altruism being a motivation for many current non-donors, people would respond more positively if appeals to donation were structured around their sense of community and social networks. A recent poll found that 64% of the respondent said they would be motivated to give blood if they saw "an advertisement of a person from your community who received donated blood talking about how blood donation saved their life" (Ipsos-Reid, 2003: 36). As well, 41% stated that they would be motivated to give blood if a doctor from their community made the appeal (Ipsos-Reid, 2003: 36). These findings support the use of a social capital perspective in that they seem to suggest that people would respond more readily to blood donation appeals if they were located within their community and meaningful social sphere, rather than general appeals made to individual altruism. Thus, people are willing to participate if such behaviour supports the needs of their community directly, thereby giving their participation meaning as a member of important social relationships. Blood donation appeals focused on individual altruism have not been able to produce the necessary increase in donors (CBS, data warehouse, 2003). Although most donor appeals have focused on the individual, the CBS has begun to collect data comparing single donation to groupbased donation within their Life Link programs. The findings reveal that group-based donation strategies are able to produce higher rates of yearly donation than are individual based strategies. For example, within 2003, 30% of Life Link donors gave blood 3-4 times this year as compared to 15% of single donors (CBS, 2003: 20). As well, 35% of Life Link donors gave two times per year as compared to 20% of single donors (CBS, 2003: 20). This suggests that targeting donation strategies to groups and communities results in better donation rates than single donors. These findings contradict those of the psychological research, which suggests that external motivations such as social pressure and social obligation are counter-productive to continued donation (Piliavin and Callero, 1991). Viewed within a social capital framework, it may be suggested that such networks and communities provide the motivation to donate that altruistic appeals may not.  54  Thus, participating within social networks that have value, and in which trust is inherent, provides both personal meaning and motivation to donate. As most of these individuals have not donated in the past, research must explore what is unique about these social contexts that motivates people to donate blood, when they haven't done so in the past. The demographic literature has shown that there exist strong ethnic differences in blood donation rates (Glynn et al, 2002; Boulware, 2002). These findings are important as the latest Canadian census revealed that 13.4% of Canada's population belongs to a visible minority (www.statscan.ca). with areas in BC such as Richmond and Surrey having numbers even higher with 60% and 37% respectively (www.statscan.ca). These demographics provide a challenge to blood collection, with the need to identify strategies that would relate to the distinct needs of such communities as well as identify potential barriers to donation. Therefore, using a social capital perspective may help to identify how ethnic community processes of social network formation may serve as influences to donate. The relationship between volunteering and social capital is an important aspect of social capital analysis. Within such an analysis, levels of volunteering and social capital are related, in that, communities that have higher rates of participation in volunteering are thought to have higher rates of social integration and thus social capital. Yet, the blood donation literature has found contradictory evidence to the relationship between volunteering and blood donation (Piliavin and Callero, 1991; Healy, 2000; Putnam, 2000). Therefore, research needs to explore whether the processes of social capital differ for blood donation as compared to other voluntary activities. If research could demonstrate a causal relationship between volunteering and blood donation, strategies could be developed to target potential donors from the existing volunteering pool. Whereas, if research indicated that these two activities are seen as distinct, it would give insight to understanding what about blood donation is unique as compared to other types of volunteering.  55  As stated previously, research on non-donation has been descriptive rather than explanatory, as it has been done in the absence of a theoretical perspective thereby offering little explanatory power to describe findings. Therefore, research must employ a theoretical analysis of  risk perception and construction in order to provide a  framework with which to view  explanations for non-donation. This literature suggests that modernity has produced an increased sense of risk consciousness within society. Such consciousness is coupled with a declining trust in expertise, because of the failure of science to protect us from harm. The identification of risk as a barrier to non-donation is not surprising as past experience in Canada with the failures of the blood system may have contributed to an increase in risk consciousness among Canadians. As well, emerging pathogens such as vCJD and West Nile have kept Canadian conscious of the existence of potential risks associated with the blood supply. Scant research has been conducted on the role that risk perception and consciousness play on decisions to donate. Therefore, it is important that research attempt to understand how and why risk perceptions differ for donors and non-donors. Using a risk analysis in conjunction with social capital will allow research to explore whether the processes of trust and reciprocity, residing within social network relationships, may help to overcome risk perceptions that stand as a barrier to donation. This research sees blood donation as a fundamentally social act occurring within a context of social network relationships, trust and in response to obligation and reciprocity within community networks.  As this thesis has attempted to show, blood donation can best be  understood through an examination of the social structural factors that influence blood donation . Linking the act of donation to meaningful aspects within  the culture and social network  relationships of both donors and non-donors, may foster participation in blood donation. Thus, focusing on the social structural influences to donation and locating such influences within an inter-related framework of social capital, trust and risk, the research questions that have guided this paper are:  56  How are the social processes that influence some people to donate different than those that lead others not to donate? An extension of this question, directly related to the processes of social capital, asks: Is blood donation better understood as a representation of social relationships established on trust and reciprocity rather than individual altruism? Paying particular attention to non-donation, the final research question asks: How can the trust established within social network relationships mediate perceptions of risk that stand as a barrier to donation? In order to answer the research questions, one should make use of the blood collection programs that exist at the CBS. Currently, the collection of blood is achieved through strategies that target single donors as well as group-based donation through the Life Link program. Recently, the BC/Yukon division of the CBS has begun to collect preliminary data on the different rates of donation between single and group donors.  This would be an important place  to begin such research, as the appeals used to recruit donors within each context are markedly different. The Life Link program actively uses social relationships and community membership to encourage donors to give blood. In contrast, single donors are targeted almost exclusively through media appeals that encourage people to respond out of altruism. To date, no research on motivation has been conducted by the CBS as donation strategies are the result of social marketing techniques and demographic data collected by Ipsos-Reid. Along with the Life Link program, the CBS organizes mobile clinics within various communities in BC. Often, these clinics use community-based themes to encourage donation, such as religion, ethnicity and shared belief systems. One such example that has been discussed are the blood drives held in Surrey. In order to motivate members of the Sikh commumty to donate blood, such donation camps are held in honour of the victims of the massacre of thousands of Sikhs in India in 1984. These blood drives would provide a unique opportunity to study the motivations of those involved, so as to understand how such social context of giving influences the decision to donate blood. As well, it would provide the opportunity to study non-donation  57  within the same context, to possibly provide an understanding as to how the social processes that provide motivation for some, stands as a barrier to others.  Additionally, this context will be  useful in which to explore issues related to risk consciousness and risk perception associated with non-donation as well as provide a basis for comparison with donors. One challenge that emerges with using a social capital approach, is that the norms of altruism are difficult to distinguish from those of trust and reciprocity. Although this distinction may seem somewhat trivial, such knowledge is necessary to support a social capital framework. As the research questions focus specifically on trust and reciprocity as fundamental to donation, the research design must attempt to achieve such a distinction. This work has been conducted previously (Carter and Castillo, 2002; Gneezy, Guth and Verboven, 2000) , therefore it may be important to draw upon the methods used within the aforementioned studies as a basis. Currently, only 3% of the Canadian population donate blood (CBS, data warehouse, 2003). The CBS has indicated that they require a 9% increase in donors in order to meet blood needs and prevent blood shortages. While much research has been conducted on the motivations of individuals to donate blood, such research has not been able to explain why most people do not participate in blood donation.  Therefore, while important, it has not been able to produce a  higher percentage of donors, therefore, research must attempt to examine other social determinants of blood donation. The premise of this project is that blood donation is best understood through an examination of the social context in which this act occurs, seeing donation as a result of meaningful social and cultural relationships, rather than individual altruism. Understanding the social structural factors that influence donation will help to identify strategies to increase donation, diversify the donor base and provide an important dimension to the existing body of literature on blood donation.  58  \  59  References cited Arrow, Kenneth J. 1972. "Gifts and Exchanges" in Philosophy and Public Affairs, 1, no. 4: 34362. Beal, R. 1999. "Deferred blood donors and their care" in Transfusion Medicine Review, 13(2): 89-94. Beck, U. (1992). Risk Society: Towards a New Modernity. London: Sage. Boe, G.P. 1976. 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Miser, eds., Research in psychology and medicine, Vol. 2, New York: Acadia press. Ying, Wu, Simone A. Glynn, George B. Schreiber, David J. Wright, Annie Lo, Edward L. Murphy, Steven H. Kleinman, and George Garratty. 2001. "First-time blood donors: demographic trends" in Transfusion, 41: 360-364.  62  

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