Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 1 | 15 ORIGINAL RESEARCH Voluntary blood donation promotion in Haute Matsiatra region of Madagascar Jocia Fenomanana1, Heritiana Gisèle Ramaminiaina1, Fidiniaina Mamy Randriatsarafara2, Zely Arivelo Randriamanantany3 1Service laboratoire CHU Andrainjato Fianarantsoa 301 Madagascar; 2Département de Santé Publique Université d’Antananarivo ; 3Direction de la transfusion sanguine Tananarive Madagascar and Direction Générale de Fourni- ture des Soins Ministère de la Santé Publique Madagascar ; Corresponding author: Jocia Fenomanana; Address: Service laboratoire CHU Andrainjato Fianarantsoa 301 Madagascar ; E-mail: jfenomanana@yahoo.fr mailto:jfenomanana@yahoo.fr Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 2 | 15 Abstract Aims: Access to sufficient, secure supplies of blood and safe transfusion services is an essential part of any strong health system. The Haute Matsiatra region has a need for blood and blood products that exceeds current availability (only 7% of needs are met). The aim of this study ls to assess community knowledge, attitude, and practice regarding voluntary blood donation in order to identify the obstacles. Methods: We have conducted a community-based cross-sectional study from 26th to 31th July 2019 within a sample of 300 subjects using a structured questionnaire and face-to-face interview. Data were analyzed using R software version 4.0.2. Results: All participants were unanimous about vital role of blood so that 62.3% were willing to donate blood but only 13% have ever donated blood. The majority of respondents (60.0%) had never heard sensitization about blood donation. The reason for non-donation were related to fears of needlestick injuries during the blood collect (38.3%), fear of blood borne diseases (17%), the lack of sensitization (6%). There was a positive significant relationship between level of educa- tion and willingness to donate blood (p-value <0, 05). The likelihood of blood donation was found to be higher among male participant 28 (71.8%) p<0.05, and among >45 years group (21.4 %) p= 0.03. Among those who ever donated blood, only 37 (26.6%) of them have received sensi- tization about donation. Conclusion: There is growing interest in blood donation among the population. Activities to pro- mote blood volunteer donation should take into account the demotivating reasons for blood do- nation. Source of funding : None Conflict of interest statement: The authors report no conflicts of interest in this work. Authors’ contributions : All authors contributed toward data analysis, drafting and critically revising the paper and agree to be accountable for all aspects of the work. Acknowledgments : We thank all those who, directly or indirectly, have contributed to this pub- lication. Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 3 | 15 Introduction Access to sufficient, secure supplies of blood and safe transfusion services is an essential part of any strong health system (1). Blood transfusions contribute for saving patients whose lives are at risk. They can help patients who have a life-threatening disease, compli- cations during pregnancy and childbirth, se- vere trauma, surgical procedures. They are also regularly used for patients with hemato- logic disease such as sickle cell disease, tha- lassemia and hemophilia (2). Despite ad- vanced research, there is currently no substi- tute for human blood (3). According to the World Health Organization (WHO), about 118.5 million blood donations are collected around the world, in which 40% are collected in high-income countries, home to 16% of the world’s population (4). Unpaid voluntary do- nors have the lowest rates of transfusion-as- sociated infections and are the ideal popula- tion from which to recruit donors as bloods are given for genuine altruistic reasons. Vol- untary donors do not have any reason to give false information about lifestyle factors which might place them at risk of transmit- ting infectious agents. There is therefore a re- duced risk of obtaining blood during the 'win- dow' period of HIV infection (5). The WHO’s goal is to obtain for each country all their respective blood supplies through vol- untary unpaid donors, in accordance with the art 28.72 of World Health Assembly adopted resolution in 1975 (6). In Madagascar, the blood donation rate in 2013 was 1.0 unit per 1000 inhabitants. Among all donors, only 18.6% are voluntary non remunerated (7). The region of Haute Matsiatra, in particular, has a need for blood and blood products that exceeds current availability (only 7 % of needs are met). The voluntary blood donor insufficiency is a major challenge in this area even if information about donation is offered regularly (16.41% in 2019: Haute Matsiatra region blood bank, unpublished data, 2019). Replacement blood donors recruited by fam- ilies are the major source of blood in this re- gion. This situation contributes to the persis- tent high mortality rates associated with po- tentially reversible conditions such as haem- orrhage and anaemia. Factors affecting blood donation often vary in various populations (8) (9). Therefore, better understanding on the level of community knowledge, attitude, and the practice of donors may help to strengthen the blood donation program in this area. In order to identify obstacles to blood donation among the population of Haute Matsiatra region, we have conducted a pre- liminary survey that aim to assess knowledge, attitude, and practice towards blood donation and its associated factors. Methods We implemented a cross-sectional com- munity-based study in the Haute Matsiatra region. Haute Matsiatra is located at 400km from the capital city of Madagas- car. Based on Malagasy population and housing census 2019 estimation, the total population of this region was estimated 1 447 296 inhabitants, 189 879 of which are urban populations (10). Multi-stage sampling technique was used to in order to recruit the study participants. On the first stage, 6 fokontany (equivalent of village) were selected from the total of 50 of the region by lottery method. We used then a systematic random sampling technique to select 50 households per fokontany. To se- lect one study participant per household we employed a lottery method. Study pop- ulation: All adults aged 18 - 65 years re- siding in Haute Matsiatra region were the source population. They were selected by multi-stage sampling technique and lived in the study area for at least six months Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 4 | 15 were included. Sample size determination: We calculated the sample size with a sin- gle population proportion formula using 95 % CI and 5 % margin of error. The sample size was found to be N=300 after considering a 1.69 % non-response rate. Data processing and analysis: Malagasy structured questionnaire was used to col- lect the data at each selected household. The tools were developed after reviewing of relevant literatures and adapted to the context of the study area (11). Information on the sociodemographic characteristics (15 questions), knowledge (9 questions), attitude (17 questions), and practice-re- lated questions (12 questions) on blood donation were included. Then, separated face to face interview from questionnaire data were entered into R software version 4.0.2 for univariate and multivariate anal- ysis. Ethical considerations: The study was ap- proved by an ethics committee. Written in- formed consent was obtained from all the study participants. They were adequately pre- informed of the aim and the implication of the study and were told about their right to refuse or withdraw their verbal consent to partici- pate in the research. Confidentiality of infor- mation was kept including omitting personal identifiers such as the name of the respond- ent. Results Sociodemographic characteristics: From the calculated 305 sample size, 5 subjects re- cruited was not related to the sample size, 300 participants were involved in the study. A to- tal of 122 (40.7%) participants were in the age group of 18-25 years, more than half 167 (55.7%) were females and 175 (58.3%) were married (Table 1). Table 1: Sociodemographic characteristics of the study participants (n=300) Variables Frequency n=300 Percentage (%) Age group in years 18-25) 122 40,7 26-35) 82 27,3 36-45) 40 13,3 > 45 56 18,7 Gender Female 167 55.7 Male 133 44.3 Marital status Married 175 58,3 Single 104 34,7 Separated 11 3,7 Widowed 10 3,3 Religion Christian 298 99.3 Other 2 0.7 Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 5 | 15 *tertiary sector: commerce, administration, transport, financial and real estate activities, business and personal services, education, health and social work Knowledge about voluntary blood donation The majority of respondents 180 (60.0%) had never heard sensitization about blood dona- tion. Mass media was the main source of in- formation of 186 (62.7%) participants. Among the 300 study participants, 263 (87.7%) were affirmed that blood transfusion “can save life”. Only 13 (4.4%) study partic- ipants had the right answers concerning min- imum criteria for blood donation (age 18-65 years, weight above 45kg, basic good health). Two hundred eighty-seven (95.7%) partici- pants replied that hospital is the only site of blood collection. Digestive hemorrhage, ane- mia, accident were the main cited indications of blood transfusion, 69 (23%) participants didn’t have any idea. Two hundred and ten participants (70.0%) replied that donating blood advantages were “to save life”, “to benefit from free analysis”12 (4.0%), “to earn money”6 (2%). Cited disadvantages were 55 (18.4%) “fear of degraded health after donation”, 6 (2.0%) “fear of acquired diseases”, 4 (1.3%) “fear of bloodborne disease”, 3 (1.0%) “fear of anemia”, 1 (0.3%) “fear of sudden death after donation” (Table 2). Table 2: Knowledge about voluntary blood donation (n=300) Variables Frequency n=300 Percentage (%) Main cited indications of blood donation Digestive hemorrage 96 32.0 Anemia 53 17.7 Bleeding 44 14.7 Accident injuries 17 5.6 Delivery 9 3.0 Surgical intervention 12 4.0 Do not have any idea 69 23.0 Main cited advantages of blood donation Educational status Illiterate 15 5 Elementary education 101 33.7 Secondary education 111 37.0 graduated education 73 24.3 Occupation sector Primary 152 50.7 Secundary 37 12.3 Tertiary* 111 37.0 Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 6 | 15 Satisfaction saving life 210 70.0 To ameliorate health 47 15.7 Benefit from free analysis 12 4.0 To earn money 6 2.0 No advantages 25 8.3 Main cited disadvantages of blood donation Degraded health after donation 55 18.4 Risk of acquired diseases 6 2.0 Blood born infections 4 1.3 Anemia 3 1.0 sudden death after donation 1 0.3 No disadvantages 214 71.3 Do not have any idea 17 5.7 Attitude toward voluntary blood donation Among respondents, 153 (51%) of them ap- prove of voluntary blood donation but only 49 (16.3%) showed their willingness to do- nate blood in the future if needed (table 3). The likelihood of favorable attitudes towards blood donation was higher among male gen- der (36.3% p<0.05), those who attended sec- ondary school (28 % p<0.005). Media user had higher chance of having favorable atti- tude compared to other source of information user (42% p<0.05). About 34.3% of those who had previous sen- sitization had favorable attitude towards blood donation (Table 4). Table 3: Study participants’ attitude toward voluntary blood donation (n=300) Variables Frequency n=300 Percentage (%) Do you approuve of voluntary blood donation? Approve 153 51.0 Strongly approve 111 37.0 disapprove 18 6.0 I do not know 18 6.0 Have you ever been sollicited for blood donation ? Yes 49 16.3 No 251 83.7 Are you motivated to donate blood for a relative if there is need? Yes 243 81.0 No 57 19.0 What reasons could motivate you to blood donation ? Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 7 | 15 To benefif from free blood tests 121 40.3 Fear of not receiving blood when need 88 29.3 To earn money 65 21.7 To save life 17 5.7 For the maintenance of good health 9 3.0 Table 4: Factors associated with the attitudes towards blood donation among participants (N=300) Variables Attitude to donate blood p- value Favorable % Unfavorable % Age 0.02 18-25) 88 29.33 34 11.34 26-35) 48 16.00 34 11.34 36-45) 20 6.66 20 6.66 > 45 ans 31 10.34 25 8.33 Gender 0.29 Male 109 36.33 58 19.33 Female 78 26.00 55 18.34 Occupation sector 0.00 Primary 67 22.33 85 28.34 Secundary 31 10.33 6 2.00 Tertiary 89 29.66 22 7.34 Marital status 0.00 Married 90 30.00 85 28.34 Single 83 27.67 21 7.00 Widowed 8 2.67 2 0.66 Separated 6 2.00 5 1.66 Educational status 0.00 Illiterate 2 0.66 13 4.34 Elementary education 35 11.66 66 22.00 Secondary education 84 28.00 27 9.00 Undergraduate education 66 22.00 7 2.34 Source of information 0.00 Media 126 42.00 60 20.00 Medecin 33 11.00 4 1.34 Community worker 19 6.33 37 12.34 Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 8 | 15 Friends 5 1.66 5 1.66 Other 4 1.33 7 2.34 Previous sensitization 0.00 Yes 103 34.33 36 12.00 No 84 28.00 77 25.67 The mainly cited barriers for blood donation related to fears of needlestick injuries during the blood collect (38.3%), fear of blood-born diseases (17%), and lack of sensitization (6%) (Figure 1). Figure 1: Main cited barriers for blood donation (n=300) Practice of blood donation and its associ- ated factors Total number of participants who have al- ready practiced blood donation was 39 (13 %) from which 22 (56.4 %), 11 (28.2 %), 3 (3%) and 3 (7.7%) have donated respectively once, two, three and more than 3 times. The reasons for donation were to save relative’s life 22 (56.4 %), moral duty 7(17.9 %), due to efficient sensitization 6 (15.4 %), to save other peoples’ lives 4 (10.3%). Overall, the majority were satisfied with the blood collec- tion session, 6 among 39 felt not reassured. Significant factors associated to blood dona- tion was age group >35 years (41.4 %): p= 0.02, male gender, marital status (married status has positive influence). Participants having secondary school level education were more likely (22/39) to donate blood compared to those who have a high degree education: p=0.04. Among those who ever donated blood, majority 37 (34.3%) of them have received general sensitization before donation: p0.02 (Table 5). 0 5 10 15 20 25 30 35 40 Percentage… Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 9 | 15 Table 5: Factors associated with practice of blood donation among participants. (n=300) Variables Have already donated blood p- value YES % NO % Age 0.03 18-25) 9 7.4 113 92.6 26-35) 10 12.2 72 87.8 36-45) 8 20.0 32 80 > 45 ans 12 21.4 44 78.6 Gender 0.0004 Male 28 21.1 105 78.9 Female 11 6.60 156 93.4 Marital status 0.07 Married 27 15.4 148 84.6 Single 8 7.7 96 92.3 Widowed 3 30 7 70 Separated 1 9.1 10 90.9 Educationalstatus 0.04 Illiterate 0 0 15 100 Elementary education 10 9.9 91 90.1 Secondary education 22 19.8 89 80.2 Undergraduate education 7 9.6 66 90.4 Source of information 0.01 Media 29 15.6 157 84.4 Medecin 3 8.1 34 91.9 Communityworker 5 8.9 51 91.11 Friends 0 0 10 100 Others 0 0 11 100 Previous sensitization 0.02 Yes 37 34.3 102 65.7 No 2 28.00 159 72 Discussion In this study, the overall level of knowledge (about minimum criteria for blood donation) towards blood donation was found to be much lower than a community based study conducted in the Debre Markos town of Ethi- opia (56.5%) (12), in the city of Mekelle (49 %) (13), and another study, conducted among Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 10 | 15 students of health science in Addis Ababa (83 %)(14). The difference in socio-economic status and in educational status of population might explain the discrepancy with the above findings. This is possible, ‘because more ed- ucated people might be in a better position to access the media and availability of aware- ness creation at primary and secondary school and higher educational institutions’ (12). Moreover, the majority of respondents had never heard any sensitization about blood donation before the study. Partly, this might be explained by the limitations of awareness campaigns on addressing the intended goals. In addition to individual factors, the charac- teristics of the collection site - fixed or mobile - are important in explaining variation in do- nor behavior. Satisfaction with the blood bank opening hours, collection site type, the traveled distance to the medical examination site and blood collection, represent important clues for blood bank policies and interven- tions to improve donor motivation (15). Tel- evision and the internet are the most effective tools for promotion and recruitment for blood donation in Guangzhou China (16). Social media have become the second most im- portant motivation reason to recruit voluntary donor beside relatives and friends. In the study area, Facebook is the preferred social media to transmit and receive information about the blood donation process, however, access to internet is still limited compared with mass media and is not used sufficiently for awareness campaigns. For repeat donors, experience of the last donation process plays a key role, the more it is positive, the more it is motivating for the future (17). Some partic- ipants are scared of what they regard as side effects of blood donation. As per a Nigerian study, 36·1% of university graduated donors believe that they can contract Human Immu- nodeficiency Virus (HIV) and/or hepatitis in- fection from blood donation (18). It high- lights the fact that knowledge of blood dona- tion is an essential prerequisite before volun- tary blood donation, and it is an important tool for avoiding fear and building positive attitude. Creating awareness on the general public regarding HIV, HBsAg and HCV transmission and prevention should be strengthened (19). The overall intention of re- spondents to donate blood voluntarily can be due to the malagasy culture (the “fiha- vanana”) of sustaining social relationships and being generous to help anytime any- where. The findings of this study are con- sistent with studies across the world, which found overall positive attitudes towards blood donation among respondents(20), (21), (14), (22), (23). Findings were lower in other studies conducted in Karachi (42%) (23), Mekelle (61 %) (13) and Addis Ababa (68 %) due to cultural differences (14). Regarding factors affecting blood donation, a range of socio-demographic, organizational, physio- logical and psychological may influence peo- ple's willingness to donate blood (24). In the current study, factor significantly associated to favorable attitude for blood donation were age group, male gender, media and previous sensitization. Young participants were indeed significantly associated with favorable atti- tude for voluntary blood donation. This could be due to a large proportion of young adult’s state that they are able and willing to donate blood compared with elder one (25). It was also noted that male gender was significantly favorable to blood donation compared with female which is consistent with overall stud- ies across the world (26). This could be in congruent to cultural belief that male is better and stronger to take responsibility than fe- male. Also, women have to face many differ- ent temporary restrictions for blood donation because of the menstrual cycle or lactation period (27, 28). Herein, most of donors were satisfied with previous blood collection expe- Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 11 | 15 rience and felt reassured. Personal blood-do- nation experience (quality of donor recep- tion, pleasant medical staff, good atmosphere during donation, organization of blood col- lecting and processing facilities, perceived physical, psychological and social impact) was indeed cited as a significant predictor of behavioral intentions to donate blood. In fact, occurrence of positive experience may make blood donation less frightening and perhaps even attractive. One of the most important in- centive for being a donor was also the direct approach by another donor (29). Concerning the frequently cited motivation for blood do- nation, altruism was not highlighted for males compared with females, but was com- bined with 'warm glow' in novice males (30). In a sample of primary healthcare users in a Brazilian municipality, fear of blood, vasova- gal reactions, and lack of knowledge regard- ing the donation process were revealed as im- portant barriers to the decision to donate blood (26). The study showed that some of the participants had a history of blood dona- tion which are not permanent as of now. Peo- ple donate when there is a need related to family member, not because there is need of safe blood in the community. That could be due to the lack of social marketing toward blood donation and periodic sensitization in the study area. According to the study results, the greatest barrier that prevents people from donating blood were fear of needles, de- graded health, physical weakness, blood- borne disease, lack of sensitization. While lack of time and fear of blood donation were the main barriers in Saudi Arabia and some developing countries (30). The findings of this study were different to those barriers re- ported in Gangzhou China which was self‐ perception of poor health (33·1%) (16). In a Brazilian study, fear of blood, injections or vasovagal reactions, and a lack of knowledge of the donation process were revealed as im- portant barriers to the decision to donate blood (28). In a qualitative investigation of Indian non-donors living in England, lack of awareness and accessibility were prominent barriers; in contrast, there was a strong pref- erence for donated blood to be distributed within the family, as opposed to unknown re- cipients (30). Globally, ‘the greatest barrier that prevents people from donating is a lack of convenience and a lack of knowledge of the importance of donating’ (5, 8). It suggests that an intensive blood donation campaign should be promoted. This would allow people to be well informed, changing the positive at- titude of saving life through blood donation to a regular practice. Recommendations It is vital to consider, in the light of the pre- dicted shortages in blood supply, methods to maximize donation rates. As per WHO crite- ria, availability of blood in a country for transfusion should be indicated by 10 blood donations at least per 1000 population (4). In Madagascar, the number of whole blood do- nations per 1000 population was less than 5 which remains too low to cover the blood re- quirements. Donations by repeat voluntary non-remunerated blood donor is 13% (4). Promotion of blood voluntary donation should take into account the demotivating reasons for blood donation which calls gov- ernmental commitment and required the need to improve research evidence in this area of practice. Particularly, the existence of a data collection and reporting system is an im- portant element of a well-managed nationally coordinated blood transfusion programme. Adequate national data on blood availability and safety allow the area to set priorities and to further strengthen the blood system. It would be suitable to readjust the strategies for implementing the national blood transfusion policy based on the results of the target pop- ulation survey. It is then necessary to con- vince non-donors and retain regular volunteer Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 12 | 15 donors. Consequently, we suggest the follow- ing changes: - Awareness campaigns should focus on strategies to unlock obstacles to donation and insisting on common misconceptions about blood (the belief to a high risk to get infected through the process of donation, blood banks sell donated blood to patients, blood donation believed to cause physical weakness). Some information has to be clarified (the donation process does not spend more than one hours, menstruation is just a temporary contraindi- cation of blood donation). - Number of mobile collections should be in- creased to be closer to volunteers (lack of time is sometimes cited as obstacle). - Use of radio spots, TV spots, telephone messages, leaflets, the press or banners on the Internet, can serve as very good advertising media. - Guarantee an excellent reception and col- lection session to avoid negative perception about blood donation process - Promotion of research in the field of «Knowledge, attitude and practice to- wards blood donation », « donor sources of motivation », « blood donation experience ». In fact, having an adequate data on blood availability, safety and a feed-back from do- nors allow the area to set priorities and to fur- ther strengthen the regional blood system. - Training of medical staff (quality of recep- tion, humanization of care, confidence in do- nors) - Implementation of educational programs in terms of educational sessions, media presen- tations, brochures distribution, and raising awareness of students on blood donation in Haute Matsiatra region. Conclusion The study shows positive attitudes and a great interest in blood donation in the Haute Mat- siatra region. It has been identified that fear is the most significant barrier to blood dona- tion among the area population. These find- ings can be a baseline for health care profes- sionals and may contribute to develop an ed- ucational platform on blood donation at na- tional levels. References 1. Y. Abdella, A. A. Pourfathollah, H. Slama, et M. Raouf, « The role of ac- cess to affordable and quality assu- red blood and blood products for achieving Universal Health Cove- rage (Editorial) », East. Mediterr. Health J. Rev. Sante Mediterr. Orient. Al-Majallah Al-Sihhiyah Li- Sharq Al-Mutawassit, vol. 24, no 3, p. 235‑236, juin 2018, doi: 10.26719/2018.24.3.235. 2. S. Sharma, P. Sharma, et L. N. Tyler, « Transfusion of blood and blood products: indications and complica- tions », Am. Fam. Physician, vol. 83, no 6, p. 719‑724, mars 2011. 3. R. Haldar, D. Gupta, S. Chitranshi, M. K. Singh, et S. Sachan, « Artifi- cial Blood: A Futuristic Dimension of Modern Day Transfusion Sciences », Cardiovasc. Hematol. Agents Med. Chem., vol. 17, no 1, p. 11‑16, 2019, doi: 10.2174/1871525717666190617120 045. 4. « Blood safety and availability ». https://www.who.int/news- room/fact-sheets/detail/blood-safety- and-availability (consulté le juill. 29, 2020). 5. S.-R. Wang, « Willingness and Prac- tice Regarding Voluntary Unpaid Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 13 | 15 Blood Donation Among College Stu- dents in Shandong, China », Am. J. Med. Qual. Off. J. Am. Coll. Med. Qual., vol. 34, no 2, p. 207, avr. 2019, doi: 10.1177/1062860618795270. 6. « WHO | Voluntary non-remunerated blood donation », WHO. http://www.who.int/bloodsafety/vo- luntary_donation/en/ (consulté le juill. 29, 2020). 7. W. H. O. R. O. for Africa, Current status on blood safety and availabi- lity in the WHO African Region — report of the 2013 survey. WHO. Re- gional Office for Africa, 2017. 8. R. Lynch et S. Cohn, « Donor un- derstandings of blood and the body in relation to more frequent dona- tion », Vox Sang., vol. 113, no 4, p. 350‑356, mai 2018, doi: 10.1111/vox.12641. 9. C. Weidmann, S. Schneider, D. Lita- ker, E. Weck, et H. Klüter, « A spa- tial regression analysis of German community characteristics associated with voluntary non-remunerated blood donor rates », Vox Sang., vol. 102, no 1, p. 47‑54, janv. 2012, doi: 10.1111/j.1423-0410.2011.01501.x. 10. « Institut National de la Statistique de Madagascar | INSTAT – La statis- tique, un outil de gouvernance au service du développement ». https://www.instat.mg/ (consulté le juill. 29, 2020). 11. G. Godin et al., « Factors explaining the intention to give blood among the general population », Vox Sang., vol. 89, no 3, p. 140‑149, oct. 2005, doi: 10.1111/j.1423-0410.2005.00674.x. 12. Y. A. Jemberu, A. Esmael, et K. Y. Ahmed, « Knowledge, attitude and practice towards blood donation and associated factors among adults in Debre Markos town, Northwest Ethiopia », BMC Hematol., vol. 16, no 1, p. 23, 2016, doi: 10.1186/s12878-016-0062-8. 13. G. Mirutse, « Intention to Donate Blood among the Eligible Population in Mekelle City, Northern Ethiopia: Using the Theory of Planned Beha- vior », Am. J. Health Res., vol. 2, no 4, p. 158, 2014, doi: 10.11648/j.ajhr.20140204.19. 14. D. Malako, F. Yoseph, et M. L. Be- kele, « Assessment of knowledge, at- titude and practice and associated factors of blood donation among health care workers in Ethiopia: a cross-sectional study », BMC Hema- tol., vol. 19, p. 10, 2019, doi: 10.1186/s12878-019-0140-9. 15. E.-M. Merz, B. J. H. Zijlstra, et W. L. a. M. de Kort, « Blood donor show behaviour after an invitation to donate: The influence of collection site factors », Vox Sang., vol. 112, no 7, p. 628‑637, oct. 2017, doi: 10.1111/vox.12562. 16. J. Ou‐Yang, C.-H. Bei, B. He, et X. Rong, « Factors influencing blood donation: a cross-sectional survey in Guangzhou, China », Transfus. Med., vol. 27, no 4, p. 256‑267, 2017, doi: 10.1111/tme.12410. 17. A. Sümnig, M. Feig, A. Greinacher, et T. Thiele, « The role of social me- dia for blood donor motivation and recruitment », Transfusion (Paris), vol. 58, no 10, p. 2257‑2259, 2018, doi: 10.1111/trf.14823. 18. M. A. Olaiya, W. Alakija, A. Ajala, et R. O. Olatunji, « Knowledge, atti- tudes, beliefs and motivations to- wards blood donations among blood donors in Lagos, Nigeria », Transfus. Med., vol. 14, no 1, p. 13‑17, 2004, Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 14 | 15 doi: 10.1111/j.0958- 7578.2004.00474.x. 19. M. Negash, M. Ayalew, D. Ge- remew, et M. Workineh, « Seropre- valence and associated risk factors for HIV, Hepatitis B and C among blood Donors in South Gondar Dis- trict blood Bank, Northwest Ethiopia », BMC Infect. Dis., vol. 19, no 1, p. 430, mai 2019, doi: 10.1186/s12879-019-4051-y. 20. H. J. Shahshahani, M. T. Yavari, M. Attar, et M. H. Ahmadiyėh, « Knowledge, attitude and practice study about blood donation in the ur- ban population of Yazd, Iran, 2004 », Transfus. Med., vol. 16, no 6, p. 403‑409, déc. 2006, doi: 10.1111/j.1365-3148.2006.00699.x. 21. H. Mirza, F. Khan, F. J. Naeem, et B. Ashraf, « Blood Safety and Donation Knowledge, Attitude and Practice (KAP) among 1st Year Medical Stu- dents at LMDC, Lahore. », p. 3. 22. K. M. Sabu, A. Remya, V. S. Binu, et R. Vivek, « Knowledge, Attitude and Practice on Blood Donation among Health Science Students in a University campus, South India », Online Journal of Health and Allied Sciences, juill. 30, 2011. http://cogprints.org/7962/ (consulté le juill. 30, 2020). 23. Z. Ahmed, M. Zafar, A. A. Khan, M. U. Anjum, et M. A. Siddiqui, « Knowledge, Attitude and Practices about Blood Donation among Under- graduate Medical Students in Kara- chi », mars 2014, Consulté le: juill. 30, 2020. En ligne). Disponible sur: https://eresearch.qmu.ac.uk/han- dle/20.500.12289/3848. 24. B. M. Masser, K. M. White, M. K. Hyde, et D. J. Terry, « The Psycho- logy of Blood Donation: Current Research and Future Directions », Transfus. Med. Rev., vol. 22, no 3, p. 215‑233, juill. 2008, doi: 10.1016/j.tmrv.2008.02.005. 25. A. H. Misje, V. Bosnes, et H. E. Heier, « Recruiting and retaining young people as voluntary blood do- nors », Vox Sang., vol. 94, no 2, p. 119‑124, 2008, doi: 10.1111/j.1423- 0410.2007.01004.x. 26. J. M. Kabinda, S. A. Miyanga, P. Misingi, et S. Y. Ramazani, « Les hépatites B et C chez les donneurs bénévoles de sang et non rémunérés de l’Est de la République démocra- tique du Congo », Transfus. Clin. Biol., vol. 21, no 3, p. 111‑115, juin 2014, doi: 10.1016/j.tracli.2014.04.001. 27. Z. A. Randriamanantany et al., « Sé- roprévalence du VIH chez les don- neurs de sang au Centre National de Transfusion Sanguine d’Antanana- rivo de 2003 à 2009 », Rév Méd Ma- dag, vol. 2, no 2, p. 138–44, 2012. 28. S. Yang et al., « Seroprevalence of human immunodeficiency virus, hepatitis B and C viruses, and Tre- ponema pallidum infections among blood donors at Shiyan, Central China », BMC Infect. Dis., vol. 16, no 1, p. 531, 01 2016, doi: 10.1186/s12879-016-1845-z. 29. L. A. Staallekker, R. N. Stammeijer, et C. Dudok de Wit, « A Dutch blood bank and its donors », Transfusion (Paris), vol. 20, no 1, p. 66‑70, févr. 1980, doi: 10.1046/j.1537- 2995.1980.20180125042.x. 30. A. Carver, K. Chell, T. E. Davison, et B. M. Masser, « What motivates men to donate blood? A systematic review of the evidence », Vox Sang., vol. 113, no 3, p. 205‑219, avr. 2018, doi: 10.1111/vox.12625. Fenomanana J, Ramaminiaina HG, Randriatsarafara FM, Randriamanantany ZA. Voluntary blood donation promotion in Haute Matsiatra region of Madagascar (Original research). SEEJPH 2021, posted: 11 May 2021. DOI: 10.11576/seejph-4425 P a g e 15 | 15 © 2021 Fenomanana et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. __________________________________________________________________________