Countering the United States' Passive Attempts at Tackling Antibiotic Resistance - Casey Godbout

Antibiotic resistance is a major global issue that has the ability to affect any individual in a variety of circumstances. It is viewed as a pressing concern in the scientific community based on substantial costs for healthcare systems, increased morbidity and mortality, and implications for a bleak future of treating microbes. The World Health Organization's (WHO) central focus of the 2011 World Health Day was antimicrobial resistance, yet was this vital concern effectively addressed?
Resistance is an evolutionary adaptation (mutation) of a microbe due to the presence an antibiotic that tends to spread rapidly in response to excessive use and misuse. While it is now being recognized by many government and health organizations, it has been an imminent concern since the first signs of resistance to penicillin in the mid 1940s. Complacency in the 1980s, has led to a reduction in novel antibiotic development and increased number of deaths due to multidrug resistant (MDR) and extremely drug resistant (XDR) infections. In the United States alone, the annual cost of antibiotic-resistant infections ranges from $21-$34 billion and 8 million additional hospital days due to these infections (1). What was once believed to be traditionally endemic to hospital settings have subsequently become endemic in community settings as well.
Developing countries run the risk of microbes developing resistance faster due to issues of illegal, poor quality and counterfeit drugs, as well as shortages of essential medications. Additionally, individuals in poorer countries are subject to crowded and generally unsanitary conditions, which allow resistant microbes to spread and thrive (2). But why, in a medically advanced, highly developed nation do we see such excess in deaths attributable to infection with resistant microbes? Surely, the United States has the resources, sanitation, knowledge, diagnostic capabilities and greater capacity to slow the spread of inevitable adaptations and reduce illness. The answer is a unanimous yes, but the current attitude that has evolved in our society is generated by laziness, convenience of access to antibiotics and a lack of economic incentive to pursue such high standards of care.
At the patient level, individuals have grown accustomed to the ease of acquiring antibiotics from pharmacies and physicians. The first signs of a sneeze or a cough warrants the need to treat, whether or not that treatment is biologically effective. Antibiotics treat bacterial infections, not viral infections, yet patients are convinced (generally due to past experiences) that these pills still cure their symptoms. At the provider level, the conflict arises from the difficulty in conveying information to the patient, particularly when that patient is a distraught parent with a sick child. Physicians are often conflicted by the patient's need for rapid treatment, and whether or not to clinically diagnose the pathogen and take time to sufficiently explain antibiotic use to patients. This is where the overuse comes into play. On the other end, patients who do develop bacterial infections may be prescribed antibiotics and do not "take as directed" by their physician. As soon as the patient starts to feel healthy again, they discontinue use of the antibiotic, and allow any mutant/resistant microbes to survive and multiply (3). This is considered the misuse of antibiotics. Combined, overuse and misuse of antibiotics have allowed antibiotic resistance to become a serious concern in a developed nation.
In this paper, I will first analyze the flaws of the current approaches to antibiotic resistance in the United States by way of behavioral science and models. I will then make suggestions for improving the approach by synthesizing evidence-based research with patient and provider beliefs and behaviors.

Critique 1: The Health Belief model's failure to address antibiotic resistance

The Health Belief Model assumes that people are rational when making decisions about their health. Many campaigns that address antibiotic resistance utilize this model to reduce the overuse and misuse of these drugs. These campaigns focus heavily on passive education of patients, providers, and in some cases, policy makers about resistance and adherence to antibiotic regimens. The Health Belief Model assumes that a person's health related behavior depends on their perception of the severity of antibiotic resistance, the person's susceptibility to adverse antibiotic resistance outcomes, the benefit of taking preventive action against future resistance and the barriers to taking that action (3).
To illustrate the ineffectiveness of antibiotic resistance interventions, the CDC's Get Smart: Know when Antibiotics Work campaign is an ideal example. This campaign offers substantial information about when antibiotics are appropriate for use, symptom relief for non-bacterial infections, quizzes and FAQs that test individual's knowledge of antibiotic resistance, and materials for a variety of audiences including PSAs, articles, brochures, fact sheets and developing partnerships with the CDC's campaign. The assumption is that from the established partnerships, health departments and institutions may be educated and effectively disseminate information to reduce misuse and increase adherence, while simultaneously educating the general population(5).
This campaign, among others, follows the basic assumption that once people are educated about the severity of and susceptibility to antibiotic resistance, they will make rational health-related decisions:
1. Once patients comprehend that resistance correlates to ineffective treatments and potential mortality, they will reduce their demand for antibiotics.
2. Once they realize their susceptibility to antibiotic resistant microbes they will not misuse antibiotics, and adhere to their regimen.
3. Once they are educated they will understand the benefits, albeit future benefits, of not taking antibiotics with a viral infection.
4. Once they are educated there will no longer be barriers keeping them from utilizing antibiotics correctly and effectively.
These four critical perceptions of the HBM are complete fallacies in regard to antibiotic resistance. As clean-cut as they may appear, common medical practice has driven patients towards far-fetched perceptions of the growing problem.
Perceived susceptibility is low among the majority of patients. Most patients (and this applies to many disease-related situations) may not believe that this will affect them or their children directly. Additionally, even when the patient recognizes their own susceptibility, action will not occur unless the individual perceives the severity to be at such a significant level that it will cause detrimental results. People, particularly people engaging in health-related decision-making, are not rational and focus substantially on the present. This realization therefore supports the discrepancies of the HBM, because it does not address emotional factors such as fear, cultural beliefs, and social and economic factors.

Intervention I:

When tackling the issue of antibiotic resistance there is no doubt that effective education strategies are a necessary component to any intervention. Understanding the concepts associated with resistance is essential for policy-makers, public health leaders, physicians and patients as well as clear communication between parties. Education alone cannot solely be associated with resulting action however, and therefore an intervention must seek to rise above and beyond current methodologies.
Education can be classified as either passive or active. Passive education strategies aim to provide information and let the learner internalize this information and subsequently do what they want with it. Active learning strategies aim to teach by "doing." In regards to physicians, utilizing active learning strategies vs. listening to an hour lecture with PowerPoint, for example, has shown to be more beneficial. Working in one-on-one or group settings such a workshops, outreach groups, or building sessions may be most effective in physician and institutional change (3). It will help physicians at the group level, begin a cultural change and practice how to handle demanding patients by conveying the appropriate messages.
Critique 2: You can teach an old dog new tricks
Differences among antibiotic prescribing practices and use from place to place can best be validated by the Situated Learning Theory. The main premise of this behavioral theory is that "learning is not an accumulation of information, but a transformation of the individual who is moving toward full membership in the professional community" (6). Learning is also perceived as an enculturation process, in which after observation of behavior of other members of the community, individuals pick up the skills, imitate behavior and act in accordance with the community's norms (7). In the context of hospital and healthcare settings, knowledge is not solely based on what was learned, for example, in medical school, but rather what was adapted as a community and culture within the health institution. With this in mind, physicians practicing in certain health settings may be more or less likely to prescribe antibiotics to patients depending their institutions behaviors and norms. It is therefore likely to be difficult to alter any behaviors within an established medical culture, unless the adaptation is at a group level.
A major drawback in addressing antibiotic resistance comes from the preheld attitudes and beliefs of both practitioners and patients about antibiotic use. Intervention strategies that assume that passive education will result in new affirmed beliefs and a change in action are highly mistaken. Additionally, intervention strategies that assume that the proper use of antibiotics in the context of physicians, patients and healthcare systems are mutually exclusive also find little hope in reducing resistance.
Evidence-based research has concluded that internal clinician factors including knowledge, experience and training are primary factors in unnecessary prescribing of antibiotics as well as clinician specialty and level of training. The highest prescribers of antibiotics for colds, acute respiratory infections (ARIs) and bronchitis are likely to be older and practice in rural areas (4). All of these factors support differences in the culture of prescribing. Interventions like the CDC's Get Smart Campaign which focus primarily on passive learning, rather than group level, interactive teaching methods have a difficult time altering physician practices.
Patients are similar to physicians, in that they have grown accustomed to particular beliefs of antibiotic use through the hospital culture and general society. Studies show how patients seeking care for ARIs expect to receive antibiotics, and patients or parents who expect, receive them more frequently based on prior experiences. Being provided information via website, brochure, PSA, or by a doctor does not mean a patient will all of a sudden stop demanding antibiotics or appropriately adhere to their antibiotic regimen. Sociodemographic factors have also been found to be associated with excess antibiotic use, which may be related to different attitudes, knowledge and expectations in varying populations as well as physicians' attitudes about particular groups. The highest use of antibiotic therapy for colds, ARIs and bronchitis treatment falls within the <5 years of age category (3). This is representative of parents' expectations that doctors will always have the ability to provide quick antibiotic treatment that will cure their children, and alternately how doctors are faced with immense pressure from patients and social norms to do so.
A recently published study, implemented a methicillin-resistant Staphylococcus aureus (MRSA) bundle in VA hospitals across the U.S. in order to assess and prevent health care associated infections with MRSA. This initiative included universal surveillance, contact precautions, and hand hygiene practices, all of which should be the common culture of health institutions. The bundle proved to be highly effective in identifying and reducing the number of health care-associated MRSA infections. The other main focus of the study was to attempt to implement an institutional culture change. It is unbelievable that hand hygiene, contact precautions and surveillance methods are not the mainstream culture, but rather need to be implemented by means of a bundle within healthcare institutions (8).
Intervention 2: Fueling Fire with Fire
Since the Situated Learning Theory shows how physicians learn from "doing", their peers, and their adaptations to their environmental norms, this theory can also be used to counter current practices and beliefs. In many studies, physicians have expressed the need for effective dissemination and the need for more direct guidance, due to the fact that many do not perceive particular diseases or medical practices as growing problems. Physicians have commented how they comprehend the significance of a problem, but continue to aim their focus on other more immediate health issues such as myocardial infarctions (9). It is difficult to emphasize antibiotic resistance and enforce good practice particularly when it tends to lead to adverse effects on people other than the immediate recipient of the drugs (10).
Other physicians have emphasized a combination of their learning, and that their held beliefs about what are "major" issues in the medical world are strongly emphasized in their medical training and over many years in practice (9). In order to address these belief differences it is important to try and make the beliefs of pressing health problems as universal as possible, which can first try to be accomplished during medical training and developing core values. Following medical training it is up to the environment of the health care institution to effectively develop a well-rounded set of beliefs and practices surrounding antibiotic prescriptions and limiting resistance. This will make it easier for physicians to express medical knowledge and culture to patients effectively while still maintaining a strong patient-provider relationship.
Critique 3: Antibiotic resistance interventions are implemented at specific levels of the health care hierarchy and not as a concerted effort between patients, providers and policy-makers.
The American Medical Association (AMA), World Health Organization (WHO), Infectious Disease Society of America (IDSA), Centers for Disease Control (CDC), Food and Drug Administration (FDA), United States Department of Agriculture (USDA) and countless other organizations have blatantly recognized, and many have developed, recommendations, guidelines, and a vast array of materials designated to reduce antibiotic resistance both in hospitals and community settings. Many healthcare institutions currently have antibiotic resistance guidelines in place that their health professionals are assumed to appropriately adhere to, while completely disregarding economic, pharmaceutical, patient, and social norm pressures to act otherwise (11).
Guidelines are in place in many hospital settings that address prescribing antibiotics to patients, however guidelines are just that, they guide physicians when making decisions. As noted in critique 2, physicians, particularly older physicians, have difficulty adapting and forming new habits, particularly in an area that has remained stagnant and relatively consistent for many years. The CDC could update recommendations every 6-months with the newest evidence-based research, however without enforcement and concerted effort there will never be progress.
Currently the U.S. does not systematically gather data on antibiotic prescriptions and use that can be utilized to understand the manner and the degree to which antibiotics are used (1). Surveillance is also important to determine antibiotic resistance trends for a wide range of infections and pathogens, as well as the type/quantity of antibiotics most commonly used in patient care. It is considered inappropriate use when physicians prescribe broad spectrum antibiotics to a patient with an infection that must be attacked by a narrow spectrum antibiotic and vice versa. Developing trends observed by these surveillance systems, would offer support to physicians when making decisions about which antibiotics to use (if any) and relaying this information to patients (1).
Physicians and patients can do their part to reduce antibiotic resistance by prescribing appropriate antibiotics (or no antibiotics for viral infections) and adhere to antibiotic regimens, respectively. Unfortunately, these actions merely slow the emergence and transmission of resistance so the focus must also be on policy-makers and the government to keep up with resistance.
Pharmaceutical companies have placed antibiotic development on the back burner. Five new antibiotics were approved between 2003-2007, compared to 16 new antibiotics between 1983-1987 (12). In 2008, only 15 antibiotics of 167 under development had a totally new mechanism of action to tackle multidrug resistance (13). Since the 1960s only four new classes of antibiotics have been introduced and most of the new antibiotics are simply chemical derivatives of these basic scaffolds (14). Pharmaceutical companies have little incentive to develop new antibiotics due to high failure rates in clinical trials, as well as poor return on investment since they are taken for only a short period of time (13).
Another area of government regulation is antibiotic use in livestock. The largest use of antibiotics worldwide is in the production of animals for human consumption and secondly, as additives in animal feeds over long-term, low-level use (prime conditions for microbes to mutate and spread resistant strains) (15). While this is great for the producers seeking to produce large, healthy animals to sell to consumers, it is dangerous in regard to increasing antibiotic resistance. The same antibiotics used in the feed and to stimulate growth are also those used by humans to treat infections. The European Union (EU) is years ahead of the United States, and officially banned the use of antibiotics for animal growth in 2006 (16). Again, recommendations have been made by the IDSA and other organizations to ban non-judicious antibiotic use in animals, plants and marine environments; however these recommendations are not viewed as urgent problems.
The lack of new antibiotics for the future and antibiotic use in livestock production are incredibly dense, multifaceted topics that could be addressed more in depth in extended interventions. They are discussed briefly here to illustrate the depth and magnitude of the emergence of antibiotic resistant microbes and to point out that current intervention strategies do nothing to change them.
Intervention 3: Utilizing the Diffusion of Innovations Theory to initiate change

Since it is difficult to promote health behavior change and initiate new guidelines and policies that physicians and providers will ultimately follow, a new overall approach must be used. The Diffusion of Innovations theory is an excellent theory for addressing changes in health behavior at the group level. The framework specifically addresses innovation, style of communication, steps in decision making and the social context. According to Ralph Linton, diffusion include three distinct processes, "presentation of the new culture element or elements to the society, acceptance by the society, and the integration of the acceptance by the society, and the integration of the accepted element or elements into the preexisting culture" (17).
An intervention developed using the Diffusion of Innovations Theory addresses all of the drawbacks of current antibiotic resistance campaigns and approaches. The innovation is the new culture of healthcare institutions recognizing antibiotic resistance as a major health concern and physician's appropriately using antibiotics to cure bacterial infections and effectively communicate with patients. It will also include individuals within the institutions that will make sure physician's are judiciously prescribing antibiotics and will include a surveillance method as described earlier. The next aspect is the relative advantage, or the degree to which the innovation is perceived as better than prior interventions (i.e. effectiveness and cost efficiency). Reducing the emergence of multidrug resistant infections, will reduce the cost per patient within the hospital setting since multidrug resistant infections tend to resort to more expensive, last resort regimens (10).
The intervention will then address the complexity of the issue. Incorporating active learning sessions for physicians and health care professionals within a hospital will teach and reinforce the issues and implemented guidelines. There will also be bulleted reminders posted within the hospital to serve as reminders, including important facts to convey to patients.
It will be the hope that early adopters will already share the belief that antibiotic resistance is a major problem, and begin to implement changes within their institutions. It has been shown that the more charismatic and well-known particular individuals or institutions implementing the change are, the more likely others will be influenced to follow (18). Current interventions include utilizing many different modes of communication to get the word out to patients. While these modes are easy to access, they provide a plethora of conflicting opinion from source to source, and studies have shown that face-to-face exchange, specifically between a person regarded as highly professional and knowledgeable communicating with a patient, will result in a desired change of attitude. Lastly, the process can be summarized by the following:
1. Researchers gather knowledge about the growing problem and resulting effects of antibiotic resistance at the patient, physician, and health care system/economic levels.
2. The healthcare institutions and physicians are persuaded about advantages of the proposed innovation (i.e. reduce per patient costs, reduce length of stay in hospitals, reduce/slow antibiotic resistance)
3. The institutions and physicians engage in active learning activities (i.e. workshops, communication strategies, communicating with professionals about innovation) that will lead to choosing and adopting the innovation
4. The innovation is incorporated into the institution and daily practice of the physician which will be monitored
5. Reinforcement of the innovation will be achieved via discussion groups, seminars between nearby hospitals, and presentation of evidence-based findings (18).

REFERENCES

1. Infectious Diseases Society of America (IDSA) Combating Antimicrobial Resistance: Policy Recommendations to Save Lives. Clinical Infectious Diseases 2011; 52(S5):S397-S428.
2. Gould, I.M. Coping with antibiotic resistance: the impending crisis. International J of Antimicrobial Agents 2010; 36:S1-S2.
3. Ranji SR, Steinman MA, Shojania KG, Sundaram V, Lewis R, Arnold S, Gonzales R.
Antibiotic Prescribing Behavior. Vol. 4 of: Shojania KG, McDonald KM, Wachter RM, OwensDK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Agency for Healthcare Research and Quality 2006. AHRQ Publication No. 04(06)-0051-4.
4. Sharma, M., Romas, J.A. Chapter 4: Health Belief Model. In: Theoretical Foundations of Health Education and Health Promotion. Sudbury, MA: Jones & Bartlett. pgs 31-44.
5. Centers for Disease Control (CDC). Get Smart: Know When Antibiotics Work Campaign. 2011. http://www.cdc.gov/getsmart/
6. Hmelo, C.E., Evenson, D.H. Introduction: Problem-Based Learning: Gaining Insights on Learning Interactions through Multiple Methods of Inquiry (pgs. 1-19). In: Hmelo, C.E., Evenson, D.H., ed. Problem-Based Learning: A Research Perspective on Learning Interactions. Mahwah, NJ: Lawrence Erlbaum Associates, Inc., 2000.
7. Brown, J. S., Collins, A., & Dugid, P. (1989). Situated cognition and the culture of learning. Educational Researcher, 18, 32-42.
8. Jain, Rajiv, Kralovic, S.M., Evans, M.E., Ambrose, M.,Simbartl, L.A., Obrosky, S., Render, M.L., Freyberg, M.S., Jernigan, J.A., Muder, R.R., Miller, L.J., and Roselle, G.A. Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections. N Engl J Med 2011; 364:15.
9. Barlow, G., Nathwani, D., Myers, E., Sullivan, F., Stevens, N., Duffy, R., Davey, P. Identifying Barriers to the Rapid Administration of Appropriate Antibiotics in Community-Acquired Pneumonia. J of Antimicrobial Chemotherapy 2008; 61:442-451.
10. ReAct - Action on Antibiotic Resistance: Economic Aspects of Antibiotic Resistance. www.reactgroup.org.
11. University of Pennsylvania Medical Center Guidelines for Antimicrobial Therapy. 2011. Accessed from http://www.uphs.upenn.edu/bugdrug/antibiotic_manual /table%20of%20contents.htm.

12. Stubbings, William and Labishiniski, H. New Antibiotics for antibiotic-resistant bacteria. Biology Reports 2009; I:40.
13. Fischbach, M.A., Walsh, C.T. Antibiotic for Emerging Pathogens. Science 2009; 325: 1089-1093.
14. Braine, Theresa. Race Against Time to Develop New Antibiotics. Bull World Health Organization 2011; 89:88-89.
15. Silbergeld, E.K., Graham, J., Price, L.B. Industrial Food Animal Production, Antimicrobial Resistance and Human Health. Annual Review of Public Health 2008; 29:151-169.
16. Smith DL, Dushoff J, Morris G Jr (2005) Agricultural antibiotics and human health. PLoS Med 2(8): e232.
17. Dearing, J.D. Applying Diffusion of Innovations Theory to Intervention Development. Res Soc Work Pract 2009: 19:503-518.
18. Sanson-Fisher, R. W. Diffusion of Innovation Theory for Clinical Change. MJA 2004; 180: S55-56.

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.

Proposal

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.

REFERENCES

1. World Health Organization. Global Blood Safety and Availability. Blood safety Survey, 2007.

2. Allan JP. Volunteer safer than replacement donor blood: a myth revealed by evidence. ISBT Science Series 2010. 5: 1751-2824.

3. Webb , Yvonne. (2011, March 12). Health minister: no blood shortage. Trinidad Guardian. http://guardian.co.tt/news/2011/03/12/health-minister-no-blood-shortage

4. Sampath S, Ramsaran V, Parasram S, Mohammed S, Latchman S, Khunja R, Budhoo D, Poon King C, Charles KS. Attitudes towards blood donation in Trinidad and Tobago. Transfusion Medicine. 2007, 17, 83–87.

5. Charles KS, Hughes P, Gadd R, Bodkyn CJ, Rodriguez M. Evaluation of blood donor deferral causes in the Trinidad and Tobago National Blood Transfusion Service. Transfusion Medicine. 2010, 20, 11 – 14.

6. Douglas, Sean. (2011, March 12). Baptiste-Cornelis: Blood Bank running low. Trinidad Guardian. http://guardian.co.tt/news/2011/03/26/baptiste-cornelis-blood-bank-running-low

7. Clyne, Kalifa. (2011, April 21). Allyson gets needed blood. Trinidad Guardian. http://www.guardian.co.tt/news/2011/04/21/allyson-gets-needed-blood

8. Kisson, Carolyn. (2011, April 23). Bodoe appeals for more blood donors. Trinidad Express.http://www.trinidadexpress.com/news/Bodoe_appeals_for_more_blood_donors-120529554.html

9. Robinson A. Britain's blood service is committed to spirit of altruism among donors. BMJ, 1996 313 : 428.

10. Schreiber G et al. Convenience, the bane of our existence, and other barriers to donating. Transfusion. 2006,46, 545-553.

11. Piliavin JA. Why do they give the gift of life? A review of research on blood donors since 1977. Transfusion. 1990, 30, 444-459.

12. Gillespie TW, Hillyer CD. Blood donors and factors impacting the blood donation decision. Transfusion Medicine Reviews. 2002, 16, 115-130.

13. Trinidad and Tobago Ministry of Health. National Blood Transfusion Unit. Port of Spain. Trinidad and Tobago Ministry of Health. http://www.health.gov.tt/sitepages/default.aspx?id=184

14. Ajzen, I. Perceived behavioural control, self-efficacy,locus of control and the theory of planned behavior. Journal of Applied Social Psychology, 2002, 2, 1–20.

15. Davidson AR, Jaccard J. Variables that moderate the attitude-behavior relation: Results of a longitudinal survey. Journal of Personality and Social Psychology, 1979, 37, 1364-1376.

16. Manstead AS, Proffitt, C, Smart JL. Predicting and understanding mothers' infant-feeding intentions and behavior: Testing the theory of reasoned action. Journal of Personality and Social Psychology, 1983, 44(4), 657-671.

17. Barling NR, Moore SM. Prediction of cervical cancer screening using the theory of reasoned action. Psychol Rep, 1996, 79(1) 77-78.

18. Fishbein M. A theory of reasoned action: some applications and implications. Nebr Symp Motiy, 1980, 27, 65-116.

19. Giles M, Cairns E. Blood donation and Ajzen's theory of planned behaviour: An examination of perceived behavioural control. British Journal of Social Psychology, 1995, 34(2), 173-188.

20. Armitage CJ, Conner M. Efficacy of the theory of planned behaviour: a meta-analytic review. British Journal of Social Psychology, 2001, 40, 471–199.

21. Abraham, C., Wight, D. and Scott, S. (2002) Encouraging safer sex behaviours: development of a share sex education programme. In Rutter, D. and Quine, L. (eds), Changing Health Behaviours. Open University Press, Buckingham, pp. 28–48.

22. Pickford-Gordon, Lara. (2011, March 29). Panel probing Chrystal’s death can get more time. Trinidad and Tobago Newsday. http://newsday.co.tt/news/0,137977.html

23. Staff. (2011, March 31). Suspended Doctors in the Dark. Trinidad and Tobago Newsday. http://www.newsday.co.tt/news/0,138088.html

24.St Rose-Greaves, Verna. (2010, August 27). Cries for blood being heard. Trinidad Express. http://www.trinidadexpress.com/commentaries/Cries_for_blood_being_heard-101701088.html

25. Rambharat, Clarence (2011, April 5). Theatres of Death. Trinidad Express. http://www.trinidadexpress.com/commentaries/Theatres_of_death-119231524.html

26. Ariely, Dan. Predictably Irrational. HarperCollins, 2008.

27. Ganness, D. (2011, April 23). Donors angry with new blood policy. Trinidad Guardian. http://www.guardian.co.tt/lifestyle/2011/04/23/donors-angry-new-blood-policy

28. Dillard JP, Shen L. On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs. 2005, 72, 2, 144-168.

29. Pan American Health Organization. Health Systems Profile Trinidad and Tobago. Pan American Health Organization, 2008.

30. Wejnert, B. Integrating Models of Diffusion of Innovations: A Conceptual Framework. Annual Review of Sociology, 200228: 297–306.

31. Scholz C. Generation Y and Blood Donation: The Impact of Altruistic Help in a Darwiportunistic Scenario. Transfusion Med Hemother, 2010, 37(4):195-202.

32. Lefebvre RC, Flora JA. Social Marketing and Public Health Intervention. Health Education Quarterly, 1988, 15 (3), 299-315.

33. Caribbean Broadcast Media Partnership. Live Up: Love, Protect, Respect. Caribbean Broadcast Media Partnership. http://www.iliveup.com/

34. American Red Cross. Red Cross Rewards Online Store Replaces Members Life. American Red Cross. http://www.redcrossblood.org/news/pnw/red-cross-rewards-online-store-replaces-members-life

35. Public Broadcasting Service. Red Gold. Public Broadcasting Service. http://www.pbs.org/wnet/redgold/basics/bloodcollection.html

36. Lord, Richard. (2011, April 29). Chit system in blood donations back for now. Trinidad Guardian http://www.guardian.co.tt/news/2011/04/29/chit-system-blood-donations-back-now