Challenging Dogma - Spring 2011

Sunday, May 15, 2011

Infrastructural and Theoretical Challenges to Switching From the “Chit System” To Voluntary Blood Donation in Trinidad and Tobago—Natalya Maharaj

The “Chit System” of Blood Donation in Trinidad and Tobago

Blood donation and potential shortages in the blood supply are issues that are typically undervalued in developed countries like the United States. While developing and transitional countries struggle to meet the 10 donations/1000 population that is necessary to meet the minimum needs of the country, the WHO 2007 Blood Safety Survey, notes that the average donation rate among developed countries is 38.1 donations/1000 population (1). The WHO report implies that the disparity in donation rates between developed nations and developing or transitional nations is attributable to the persistent dependence on family/replacement donations or paid donations in the less developed world (1). While the myth that voluntarily donated blood is safer than blood obtained through other methods has been refuted, reliance on solely family/replacement blood donations is not sufficient to sustain a steady blood supply at the minimally required level (2).

The blood supply in Trinidad and Tobago previously relied on the “chit system,” a derivation of the family/replacement donation method. According to Dr. Anand Chatoorgoon, former Acting Medical Director of one of four major public hospitals in Trinidad and Tobago, medical professionals relied primarily on “blackmailing patients to have their relatives give blood” prior to completing medical procedures (3). Upon donation of blood, family or replacement donors were given a “chit” which could be used to retrieve blood for a patient, when necessary (4). Under this system, donors essentially owned the donated blood and ultimately decided whether a friend or relative received their blood (3). As a result, any unused blood stored in the blood bank, essentially, could not be utilized in emergencies or for other patients. Moreover, Minister of Health Therese Baptiste-Cornelis noted that the chit system “encouraged fraud among nationals” as donors resorted to selling chits for thousands of dollars to those in dire need of blood (2).

In addition to being a system that was inherently unethical and that grew to be exceedingly corrupt, the chit system was repeatedly shown to be inefficient and acquiring the blood necessary for sustaining the range of medical procedures that are performed in Trinidad and Tobago. Sampath et al. note that continuing advances in cardiac surgery, dialysis and oncology lead to an increased demand for blood, but merely 6,000 regular, non-remunerated voluntary blood donors were recorded (4). 87% of the blood donations in Trinidad and Tobago were made as replacements for family or relatives and were insufficient for sustaining the demands of the “rapidly developing health system” (4). Indeed, both Sampath et al. and Charles et al. highlighted that continued reliance on the chit system of blood donation could lead to detrimental effects on patient care in Trinidad and Tobago (4,5)

Abolition of the “Chit System”

Presumably in an effort to bring the health system of Trinidad and Tobago closer to internationally accepted standards of care and procedures, the “chit system” of blood donation quietly transitioned to a completely voluntary blood donation system in January 2011 (6). Inefficient communication of this change to the public, however, ensured that the change in the blood donation system went virtually unrecognized until March 2011. As citizens became increasingly aware that their donated blood went into a general blood bank, and not specifically to their friends or relatives, blood donation in the nation dropped significantly (3). On March 12, 2011, Minister of Health Therese Baptiste-Cornelis indicated that there was no shortage of blood in Trinidad and Tobago’s blood banks (2) but it has become increasingly evident that collections are not at levels similar to those obtained with the chit system and significantly less than optimal levels. Several newspapers reports have noted that daily donations have dropped to single digits (2). Additionally, as recently as April 20, 2011, family members of the ill Allyson Hennessy issued a public announcement calling for donation of O-positive blood, necessary for the patient’s treatment (7).

The transition from the chit system to voluntary blood donation in Trinidad and Tobago has been wrought with problems. As the resultant blood shortage becomes a more urgent issue, governmental efforts have focused on a media campaign calling for increased voluntary blood donations. To facilitate this, the four blood donation centers have remained open for 6 hours on Saturdays throughout the month of April. However, it is becoming increasingly obvious that even these efforts are unsuccessful. The Southwest Regional Health Authority has reported that, while 16 pints of blood were collected on the first Saturday blood donation drive, the daily target remains at 30-40 pints per day(8). It is clear that the government of Trinidad and Tobago cannot rely on ineffective media campaigns and lackadaisical infrastructural improvements to boost voluntary blood donations, as the mounting blood shortage can lead to a major public health problem. Indeed, the combination of the lack of proper infrastructure to facilitate accessible and easy blood donations, flawed usage of the Theory of Reasoned Action and inability to appropriately replace the ownership associated with the chit system by tapping into the sense of altruism that is important for voluntary blood donation (9), has essentially doomed the new blood donation system to failure.

Infrastructural Issues

Maintaining the blood supply in developed nations depends heavily on repeat donors (10-12). As donation rates have fallen in the United States, a number of investigators have undertaken studies to examine the major promoters and deterrents among repeat blood donors (10-12). One of the clearest physical deterrents to donation that has been identified is convenience of donation locations (10). According to Schreiber et al., “not having a convenient place to donate was the most important factor for all donors, regardless of race, ethnicity or donor status” (10). Piliavin and Gillespie et al. have highlighted that convenience is not limited to the location of blood donation sites but extends to economic constraints such as difficulty with transportation and the required time commitment, including the time away from work and length of the donation process (11, 12).

While the government of Trinidad and Tobago has undertaken drastic steps to switch to a completely voluntary blood donation system, only modest infrastructural steps have been taken to ensure the success of the new system. According to the Ministry of Health website, there are currently 4 blood donation centers in Trinidad and Tobago(13)—1 on the island of Tobago to serve the 54,000 residents across the 116 square mile area (14), and 3 on the island of Trinidad to serve approximately 1.3 million residents across a 1,981 square mile area (14). Two of the centers are located within close proximity to each other in northern Trinidad, while the third is located in southern Trinidad. These locations are not optimally accessible for the majority of the population. Indeed, transportation time alone to any of the three Trinidad locations would exceed 1 hour for the majority of the population. In addition to this strong deterrent, the blood donation centers are typically open weekly, between 8am and 4 pm, but donors are not accepted after 3pm. This prevents much of the eligible population from donating since it would require spending significant amounts of time away from work or school.

The current efforts to increase the convenience of voluntary blood donations are meager, at best. While the recent additions of Saturday donation times have the potential to increase accessibility to blood donations, it does not account for the tremendous effort required to travel to blood donation centers. Indeed, if the nation is to meet the minimum daily donation rate required to avoid a critical blood shortage of 30-50 donations per day at each of the donation centers, it is imperative that the blood donation process is made more convenient. The Ministry of Health notes that they have one mobile unit that, currently visits workplaces that have at least 20 willing blood donors (13)

Flawed Application of Theory of Reasoned Action

The Theory of Reasoned Action, first proposed by Ajzen and Fishbein, proposes that actions are a result of behavioral intentions that are based on attitudes towards the behavior and subjective norms, perceptions of the societal expectations regarding one’s actions (14). Like many of the other models traditionally employed in public health interventions, the Theory of Reasoned Action relies on logical, reasoned actions by inherently irrational individuals. Despite its flawed reliance on the expectation that intention leads to behavior, the Theory of Reasoned Action has been utilized effectively in several public health settings. Indeed, it has proven to be especially robust in prediction of repeated behaviors such as contraception usage (15), breast feeding habits (16), and cervical cancer screening (17).

The Theory of Planned Behavior is a revision of the Theory of Reasoned Action that accounts for self efficacy, or an individual’s belief that they are capable of completing an action (18). A wide body of research has indicated that the Theory of Planned Behavior can explain blood donor behavior. Giles and Cairn showed that subjective norms and perceived control accounted for 60.5% of the variance in behavioral intention among undergraduate blood donors (19). Overall, students who believed they lacked the ability to engage in blood donating were unlikely to form behavioral intentions regardless of their attitudes and subjective norms (19). Subsequent studies by Armitage and Conner also indicated that self efficacy was an important predictor of blood-donating intention (20).

While it is unclear whether a concerted effort has been made to design a public health intervention to increase voluntary blood donation, officials in Trinidad and Tobago seem to be relying partially on the Theory of Reasoned Action/Theory of Planned Behavior to appeal to the public. Since the introduction of the voluntary blood donation system in March 2011, the Ministry of Health’s media campaign has focused on two major areas: increasing public awareness of the new blood donation system and altering perceived norms about voluntary blood donation (newspaper articles). Increasing public awareness of the new blood donation system has relied primarily on expounding on the weaknesses of the formerly employed chit system and on the impending blood shortage. In the context of the Theory of Reasoned Action and the Theory of Planned Behavior, this approach is particularly ineffective because it relies on the presumption that presenting clear, rational information about the benefits of the voluntary blood donation system would alter attitudes toward voluntary blood donation.

The efforts to alter perceived norms about voluntary blood donation have been employed slightly more effectively. In combination with the calls for increased donations and weekend hours at donation centers, the media has featured images of prominent politicians, doctors and entertainers donating blood. This partially addresses the subjective norms surrounding voluntary blood donation as it moderately addresses individual’s perceptions of social sanctions of the action. However, politicians, doctors and older entertainers do not reflect the typical citizen of Trinidad and Tobago, and as a result, may ineffectively convey societal attitudes towards voluntary blood donation. An important factor of the Theory of Reasoned Action and the Theory of Planned Behavior that often isn’t accounted for is the significance of other people’s opinions on individual action. In efforts to alter subjective norms, it is therefore important to portray individuals who are from a similar population as the target audience and have a significant amount of influence on individual opinions and actions (21).

As research has shown the self efficacy plays a significant role in determining whether intention to donate blood actually materializes to voluntary donation (18-21). For regular blood donors, it has been suggested that promotional activities that emphasize quality of service including cleanliness of surroundings, efficiency of process and qualifications of staff be emphasized while emphasizing the ease of successfully donating could be effective for first time donors (21). Since the public in Trinidad and Tobago is generally wary of government health initiatives, especially given current missteps in several public hospitals (22-25), it is likely that self-efficacy among the population eligible for blood donation is low. It is therefore practical for the Ministry of Health to make a concerted effort to improve self efficacy by incorporating both suggestions for regular blood donors and first time donors in order to successfully increase voluntary donation rates.

“Ownership” of Blood

As Dan Ariely notes in Predictably Irrational, human beings are inherently irrational (26). One of the major features of irrationality in human beings is the “high price of ownership (26).” As Ariely shows, we tend to overvalue that which we own—Duke students who have received coveted tickets to an important basketball games selling price is 14 times the price that students who did not receive tickets would offer and perhaps due to cognitive dissonance, upon taking ownership of an idea, we “prize it more than it is worth” (26).

The chit system of blood donation that was previously employed in Trinidad and Tobago fostered a strong sense of ownership among blood donors. As recounted previously, family or replacement donors were given a “chit” which could be used to retrieve blood for a patient (4). The issuance of the “chit” essentially meant that the donor owned the donated blood, and as a result, would demand a high price to sacrifice it to another individual. Indeed, much of the criticism of the change to the voluntary blood donation system came from citizens who were concerned about not retaining the “right” to choose who received their donated blood (27).

Ignoring the “high price of ownership” and expecting that the transition to the voluntary blood donation could be done effortlessly with a weak media campaign probably resulted in the drastic decline in blood donations in the months subsequent to the switch. Despite the fact that the instated voluntary blood donation system would lead to a safer, more stable blood supply (2-5), the perceived threat to blood ownership over-rode the rational arguments of government officials. As a result of the strong sentiment against the threat to ownership, it is unlikely that any strong infrastructural changes and public information efforts would have increased blood donations. Indeed, the strong effect of psychological reactance (28) means that without compensating for the sacrifice of ownership, it is unlikely that any efforts to alter the blood donation system would succeed.


In order for the voluntary blood donation system to be effectively implemented in Trinidad and Tobago, a comprehensive effort needs to be made to correct the infrastructural problems, to successfully market the new system to citizens, and to simultaneously appeal to citizens’ sense of altruism and to compensate for the loss of “ownership.”

Infrastructural Improvements

A wide body of research has indicated that the ease of blood donation—especially related to location of donation centers and the required time commitment, including the time away from work and length of the donation process—is one of the major determinants of whether first time and repeat blood donors continue to donate blood (10-12). While improving the facilities available for blood donation in Trinidad and Tobago alone does not ensure the success of the voluntary blood donation system, it is important to address these physical deterrents if blood is to be collected safely and efficiently.

Though there are currently only four blood donation centers at the major general hospitals in the two island state, there are 84 regional health centers in Trinidad and 18 regional health centers in Tobago (29). These regional health centers provide a range of primary care and preventive care services to a large portion of the population (29). Unlike the major hospitals, these health centers are more easily accessible to the general public and should be recognized as prime areas for boosting blood donations. Having a location that is more convenient to homes and workplaces could serve as a significant encouragement for citizens to donate blood. However, like many of the public health institutions in Trinidad and Tobago, health centers are open only during working hours. Increasing hours at these centers on several days during the week and on weekends , coupled with comprehensive outreach efforts, could lead to increases in blood donation.

While extending blood donation facilities to regional health centers addresses some of the issues regarding the physical barriers to blood donation in Trinidad and Tobago, the challenges of sacrificing a significant amount of time for blood donation still remain. Employing mobile blood banks in a wider range of functions is one of the best ways of efficiently and effectively increasing blood donations. Clearly, the single mobile blood bank currently in use in Trinidad and Tobago is not sufficient to serve the needs of the nation’s health system. In order to efficiently and effectively collect needed blood, it would be wise to employ the mobile blood bank in a wider range of functions and to invest in mobile blood banks for regional health authorities. Investment in multiple mobile blood banks for the six regional health administrations would help to make blood donation less of a time-costly task. Multiple mobile blood banks can easily be utilized to visit large University and high school campuses, government workplaces, or even centralized entertainment areas. The increase in blood donations that would correspond with more resourceful utilization of this resource is easily foreseeable.

Combating Negative Subjective Norms: Diffusion of Innovations Theory and Marketing Theory

The Theory of Reasoned Action/Planned Action has proven to be an accurate predictor of many health behaviors including blood donation patterns (14-20). It is clear from this body of research that self-efficacy and subjective norms about blood donation play a significant role in determining whether an individual ultimately donates blood (14-20). While current publicity efforts by the Health Ministry of Trinidad and Tobago has focused on rational explanations for the switch to the voluntary donation system and some efforts to convey altered norms, without clear direction and target audiences, it will be difficult for actual changes in norms to hold and lead to more approval for the change in the system.

While it is important that the new voluntary blood donation system is accepted by the majority of citizens of Trinidad and Tobago, developing a media campaign that effectively targets all sectors of the population may be difficult. The diffusion of innovations theory suggests that for an innovation to be adopted in a self-sustaining manner, it must first reach a critical mass of adoption (30). Since young adults are more likely to fit the characteristics of healthy donors, have been shown to be more prone to identify with behaviors synonymous with morality, altruism and civic responsibility (31) and are likely to have wider social networks, they seem to be an appropriate population to target a strong marketing campaign. Indeed, assuming that the diffusion of innovations theory can be applied to this situation, effectively eliciting change in behavior in young adults—and consequently, others in their social circle—could lead to redefinition of social norms surrounding voluntary blood donation.

Relying on the diffusion of innovations theory, however, depends on effectively marketing the intervention to the early-adopters (30). Social marketing is a group level model that has been successfully employed in “broad-based behavior change programs”, especially at the community level (32). The Pawtucket Heart Health Program and the Stanford Five Cities Project have been cited as two of the most successful applications of social marketing to the planning, implementation, and analysis of public health interventions (32). Social marketing has proven to be effective at the community level due to two major factors of the model: the reliance on consumer orientation and audience analysis and the integration of the “marketing mix” of blending “product, price, place and promotion” into public health interventions (32).

As Scholz notes, Generation Y—individuals born between 1981 and 2001—have been shown to have incorporated general values such as “collectivism, positivity, moralism, confidence and civic-mindedness” into their vision of the world and the roles they might play in it (31). As a result, younger adults tend to value altruism as a trait in themselves and in their social environment very highly (31). Translating that altruism to the act of donating blood, however, relies on the partially on “relevant norms” that are implied in their immediate society.

Notable social marketing campaigns with young adults in the Caribbean have succeeded in altering perceived norms about sexual health issues and HIV testing (33). One of the most prominent of these campaigns is the popular “Live Up: Love, Respect, Protect” media campaign (33). This effort has rebranded sexual health to not only make it less taboo in the community but also successfully tore down social mores that might have restricted safe sexual health practices. Indeed, the effort has combined this rebranding with appropriate use of television campaigns to make it seem ‘cool’ and ‘normal’ for any regular young adult to participate in HIV testing. Adopting a similar approach to rebranding and marketing voluntary blood donation could be similarly effective among the same demographic that the Live Up campaign targets. First, voluntary blood donation could be rebranded as “3:1”, representing the number of lives that can be saved with one pint of blood (34). Subsequent advertisements will then focus on ‘cool’, ‘normal’ young adults engaging in fun activities, but who convey clearly that they enjoy donating blood because of the easy contribution to society. The rebranding and media campaign should then be paired with social networking sites to develop a community among young adult, voluntary blood donors. Provided that infrastructural improvements are made to in fact make blood donation easy, it is probable that the combination of these efforts could successfully lead to changes in behavior, and consequently norms, within young adults. Diffusion of innovations and the social networking aspect could then be relied on to lead to behavioral changes among other sectors of society.

Rewards for Donation

The sense of ownership that the chit system fostered is one of the strongest factors against public acceptance of the voluntary blood donation system and needs to be properly countered if the voluntary blood donation system is to succeed. In addition to effectively using the described marketing strategy to appeal to citizens’ sense of altruism, tangible incentives need to be provided to encourage sustained voluntary blood donations.
The American Red Cross collects approximately half of the donated blood in the United States (35). Indeed, through effective marketing and branding, the American Red Cross has succeeded in both appealing to altruism among donors and making blood donation a “movement” by labeling donors as “members for life” (34). Recent efforts by the organization have focused on developing diverse ways to thank repeat donors (34). The most recent development includes an online “Red Cross Rewards: Your Link to Life” store (34). Voluntary blood donors collect points under a membership number and are able to redeem those points for a variety of merchandise (34). Utilizing a similar model of rewards for voluntary blood donors in Trinidad and Tobago would be a strong incentive to encourage voluntary blood donation and would reinforce the idea of a “movement” to donate blood expressed by marketing strategies. The concept of ownership of donated blood will persist in Trinidad and Tobago until norms targeted in the marketing campaign take firm hold in the society. However, by pairing incentives with the idea of a voluntary blood donation movement, behaviors may be more likely to be altered and result in a gradual acceptance of the voluntary blood donation system.

Recent Developments

On April 28, 2011, Minister of Health Therese Baptiste-Cornelis reported that the chit system of blood donation had been reinstated temporarily as the new voluntary blood donation system had “not given desired results”(36). In an effort to avert the blood shortages and declines in blood donation rates that occurred upon the first attempt to implement the voluntary blood donation system, “six mobile blood units were purchased for each of the six regional authorities”( 36). While this investment is necessary to ensure the eventual success of the voluntary blood donation system in Trinidad and Tobago, the Ministry of Health needs to realize that infrastructural improvements must be complemented with a comprehensive public health intervention in order for voluntary blood donations to sustain the long term needs of the country.


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