importance of research abstract to a donor

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• My Account Login
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 08 April 2024

Unveiling blood donation knowledge, attitude, and practices among 12,606 university students: a cross-sectional study across 16 countries

• Nael Kamel Eltewacy 1 , 2   na1 ,
• Hossam Tharwat Ali 2 , 3   na1 ,
• Tarek A. Owais 2 , 4 ,
• Souad Alkanj 5 ,
• EARG Collaborators &
• Mahmoud A. Ebada   ORCID: orcid.org/0000-0001-5284-2929 5 , 6   na1  

Scientific Reports volume  14 , Article number:  8219 ( 2024 ) Cite this article

1287 Accesses

1 Altmetric

Metrics details

• Health care
• Medical research

We assessed university students’ knowledge, attitude, and practice toward blood donation and identified the factors that promote or hinder their willingness to donate. We employed a multicenter cross-sectional design, collecting data from August to October 2022 through self-administered questionnaires available in Arabic and English. Both online (Google Forms) and paper surveys were utilized. Data were analyzed using R Statistical Software (v4.1.3; R Core Team 2022). A total of 12,606 university students (7966 females and 4640 males) from 16 countries completed the questionnaire; of them, 28.5% had a good knowledge level regarding blood donation, and 22.7% had donated blood at least once. Students in health science colleges had significantly more awareness of blood donation ( p -value < 0.001), but there were no significant differences in practice ( p -value = 0.8). Barriers to donation included not being asked (37%), medical ineligibility (33%), fear of pain or infection (18%), concerns about negative health effects (18%), difficulty accessing donation centers (15%), and medical mistrust (14%). Individuals aged > 20 years had significantly higher odds of possessing a high knowledge level (adjusted odds ratio [aOR] 1.77, p  < 0.001). Private and international university enrollment was associated with increased knowledge (aOR 1.19, p -value < 0.001 and aOR 1.44, p -value = 0.003), while non-health science college students had lower odds (aOR 0.36, p  < 0.001). Regarding blood donation status, participants > 20 years old were more likely to donate (aOR 2.21, p  < 0.001). Conversely, being female, having congenital or chronic diseases, and possessing low knowledge levels were associated with decreased odds of blood donation (all p  < 0.05). University students show insufficient knowledge about blood donation, with health science students displaying higher awareness levels. Despite their positive attitudes, blood donation rates remain low across all disciplines. It is imperative to enhance education and accessibility to foster a culture of blood donation among students.

Similar content being viewed by others

Attitudes of blood donors to their sample and data donation for biobanking

Variations in racial and ethnic groups’ trust in researchers associated with willingness to participate in research

Attitudes and factors influencing organ donation decision-making in Damascus, Syria: a cross-sectional study

Introduction.

Blood is a vital human body component, constantly breaking down and synthesizing through natural processes. Despite remarkable advancements in medicine and technology, artificial synthesis of blood is still impossible, rendering donation the sole means of providing blood and its components 1 . With the rise in life expectancy, traumatic accidents, blood diseases, cancers, and obstetrical complications, blood transfusion has become an essential management approach for numerous life-threatening conditions 2 , 3 , 4 .

Providing sufficient, secure, accessible blood is challenging in developing nations 5 . Every year, over 112 million units of blood are collected, with nearly half of them obtained in high-income nations. Additionally, on average, the donation rate in high-income nations is nine times greater than in low- and middle-income countries (LMICs) 6 . As a result, LMICs have greater blood demands but lack a maintained blood supply 5 , 7 .

According to the World Health Organization (WHO), Red Cross, and Red Crescent Societies, there are three categories of blood donations: voluntary, replacement, or paid donation 8 . In several countries, the majority of blood is obtained from replacement donors in hospitals, who donate when a friend or family member is in need. Nevertheless, voluntary donation is the most dependable way to fulfill national blood transfusion needs 9 . Donors who voluntarily donate blood once or twice a year are considered the safest because they are not incentivized to provide false information in order to donate 10 .

However, only 62 countries currently have blood supply systems that rely entirely on voluntary non-remunerated donations, according to the World Health Organization (WHO). As a result, blood donation organizations are exploring the potential of incentives or rewards to increase donor recruitment. Research suggests that people may be more likely to take action if they are sufficiently motivated or incentivized 11 .

As the demand for blood donors increases, recruiting them becomes more challenging. It is ideal for sourcing blood donations from young individuals who are healthy, energetic, and have the potential to be long-term prospects 3 . The World Health Organization recommends that at least 1% of the population should donate blood to meet the country’s essential blood requirement, making young adults a significant contributor. However, data shows that young people are the least represented in blood donation 12 . A recent study in Qatar revealed that only 15% of university students were blood donors 13 , while studies in Saudi Arabia reported a prevalence of blood donation among university students ranging from 19 to 45%. However, it was found that most donors only made a single donation and did not regularly donate 8 , 14 , 15 , 16 . To engage this valuable source, it is crucial to determine their knowledge, motivations, barriers, and behavior toward blood donation 17 .

Consequently, our research endeavors to bridge the knowledge gap about blood donation among university students in our region. Our primary objective is to assess their knowledge level of blood donation and ascertain whether any notable differences exist between students enrolled in health science colleges and those in non-health science colleges. Additionally, we intend to scrutinize any hurdles that could impede or diminish the donation frequency amongst this demographic. Furthermore, we endeavor to identify the incentives that drive university students to participate in blood donation. Lastly, through the dissemination of our findings, we aspire to promote consciousness about the significance of blood donation.

Materials and methods

Study design, population, and recruitment procedure.

We conducted a multicenter, cross-sectional study in 16 countries (Algeria, Bahrain, Egypt, Ghana, India, Iraq, Jordan, Libya, Morocco, Pakistan, Palestine, Saudi Arabia, Sudan, Syria, Turkey, and Yemen). The study was done between August 2022 and October 2022 using online and/or paper surveys. The study adhered to the Strengthening The Reporting of Observational Studies in Epidemiology (STROBE) Checklist in its entirety 18 . Convenience and snowball sampling methods were used to recruit eligible study participants. The sample size was calculated using Epi Info statistical calculator 7.2.5. version, a trademark of the Center for Disease Control and Prevention (CDC), with the following parameters: a confidence interval of 95%, an expected frequency of 50%, and an acceptable margin of error of 5%. The minimum sample size for each country was 400 responses.

Eligibility criteria

Male and female university students aged between 18 and 25 years from the selected countries who could respond to the questionnaire in English or Arabic were invited to participate in the study. Ineligible individuals and those who had previously filled in the survey were excluded.

The questionnaire utilized in the study was informed by numerous prior studies conducted globally 2 , 6 , 12 , 13 , 14 , 17 , 19 . The questionnaire, available in both English and Arabic, was developed as a self-administered Google form survey. To prevent the repetition of responses, the questionnaire was configured to permit only one response per associated email. The questionnaire covered four domains: sociodemographic data, knowledge about blood donation, attitude toward blood donation, and blood donation practices. Sociodemographic data included age, sex, country of residence, the original place of residence, type of university, college, and health status.

The blood donation knowledge section included information about the individual’s blood group, the right to voluntary blood donation, the amount of blood donated at a time, and the health requirements for donation. The blood donation practices section included donation status, intention to donate in the future, and if practiced, the type of donation, frequency, and quantity. The attitudes towards blood donation section included motivating and preventing factors, the role of social media, the influence of individuals on their friends, and the attitudes of university, friends, and family.

Validation and pilot study

To validate the content of the survey, experts in the hematology and public health field were invited to fill in the survey and assess the clarity, comprehension, and relevance of each question to the measured outcome (knowledge, attitude, or practice). Post validation, a pilot study was conducted on 25–35 participants from each of the 16 countries in the Middle East and North Africa (MENA) region. We employed Cronbach’s alpha to evaluate the reliability and internal consistency of the survey. The internal consistency for the knowledge section was deemed acceptable, with a value of 0.63.

Data collection

An online link to the Google form was distributed among university students through social media platforms. The link recorded the data anonymously and did not record any contact or personal information. We invited students who lacked internet access or the survey link to participate in the study by completing a paper questionnaire. Subsequently, the study collaborators entered the responses from the paper questionnaires into the study’s database. At the onset of the questionnaire, the participant was presented with the choice to grant or decline study participation. If they opted to participate, they were required to specify their preferred language, either Arabic or English. Following this, we included two confirmatory questions: the first to ascertain the individual’s eligibility to participate and the second to ensure that they had not already completed the questionnaire for the same study, thereby preventing data duplication. Participants with incomplete responses were excluded to prevent any potential information bias.

Ethical considerations

The study was conducted according to the principles of the Declaration of Helsinki (1964, last revised in 2013) 20 . This survey was voluntary, and participants provided their informed consent by marking a checkbox to signify their willingness to participate in the study. Participants’ anonymity and confidentiality were ensured throughout the study, including data collection and analysis. Initial ethical approval was obtained from the institutional review board committee (IRB) at Tanta University, Faculty of Medicine (IRB number 35698/9/22). Ethical approvals were also obtained from Egypt, Algeria, India, Iraq, Pakistan, Palestine, Libya, Saudi Arabia, Sudan, Syria, and Yemen.

Data analysis

The data were organized in a Microsoft Excel sheet and then imported and analyzed using R Statistical Software (v4.1.3; R Core Team 2022). Frequencies and percentages were used to describe the categorical variables for baseline demographic characteristics. Regarding knowledge level, the knowledge questions have been recorded as 1 for the correct answer and 0 for the incorrect one. Students who obtained a score of ≥ 70% were deemed to have a high level of knowledge, whereas those with a score of < 70% were classified as having a low level of knowledge concerning blood donation 8 , 14 , 21 . The results of the attitude and practice sections were presented as frequencies and percentages. The Chi-square test assessed the significant association between demographic characteristics, knowledge level, attitude toward blood donation, and blood donation practices. We employed univariate and multivariate regression analyses to identify predictors influencing knowledge level and donation behaviors, quantifying associations through odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CI). A p -value of ≤ 0.05 was considered significant.

Ethics approval and consent to participate

This survey was voluntary, and participants provided their informed consent by marking a checkbox to signify their willingness to take part in the study. Participants’ anonymity and confidentiality were ensured throughout the study, including data collection and analysis. Initial ethical approval was obtained from the institutional review board committee (IRB) at Tanta University, Faculty of Medicine (IRB number 35698/9/22). Ethical approvals were also obtained from the participating countries.

The study invited 14,625 individuals to complete the questionnaire, with 800 individuals either not eligible or declining participation. Therefore, 13,825 participants completed the questionnaire, with 5100 and 8725 using the English and Arabic forms, respectively. Data from 1219 participants were excluded from the analysis due to inconsistency, and the final analysis included 12,606 participants from 16 countries.

Demographic characteristics

Egypt had the highest response rate of 10% among the 16 countries, while Palestine had the lowest response rate of 4.8%. Among the study participants, 36% were aged ≤ 20 years (n = 4543), while the over-20 age group constituted 64% (n = 8063). Furthermore, 7966 participants (63.2%) identified as females, and 10,091 participants (80%) were residents of urban areas. Most participants were enrolled in governmental universities (71.4%) and health science colleges (67%). About 90.3% did not have a history of congenital or chronic disease. Further details regarding demographic characteristics are presented in Table 1 and Online Appendix S1.

Knowledge regarding blood donation

A total of 9842 participants (78.1%) were aware of their blood type, while 9760 participants (77.4%) knew about the right to voluntary blood donation. Only 5507 participants (43.7%) knew the amount of blood taken during a single donation, and 4984 participants (39.5%) knew the minimum interval between two successive donations. Additionally, 70.1% and 39.1% of participants knew the minimum age and weight requirements for donation, respectively. About 89.8% of participants knew that donated blood is tested before being transfused, while 58.9% knew that not all individuals with diabetes or hypertension could donate. Only 42.2% knew that smokers are eligible to donate, while 57.9% knew that having a fever on the donation day disqualifies a person. Meanwhile, 71.9% knew that pregnant women are ineligible to donate, while 16.1% knew that women can donate during menstruation. The health science college group had significantly higher knowledge scores than the non-health science college group ( p -value < 0.001). Overall, only 3588 participants (28.5%) demonstrated a high level of knowledge (≥ 70% of correct answers), with a significantly higher percentage in the health science college group (34.7%) compared to the non-health science college group (15.7%), with a p -value of < 0.001). See Table 2 for detailed knowledge section results.

Attitude toward blood donation

Approximately 24.2% of the participants reported receiving lectures or courses about donation, while 75% expressed their desire to receive training on blood donation. Nearly 90% of the participants reported being ready to donate blood if there was a serious shortage in the blood banks, and 79.6% encouraged nearby people to donate. Around 80% of the participants were willing to participate in any campaign organized by their university; moreover, 77.9% expressed their willingness to take responsibility for spreading accurate information about blood donation to the public. Concerning social media and blood donation calls, Facebook (26.8%), followed by Instagram (13.7%) and WhatsApp (10%), were the most commonly used platforms. Noteworthy, 43.5% of the participants reported not seeing any calls for blood donation on social media.

Additionally, 47.6% of the participants reported a positive attitude toward their friends toward blood donation, while 42.2% and 41.4% reported a positive attitude toward their universities and families, respectively. We observed significant differences in all items of the attitude section between students enrolled in health and non-health science colleges. Specifically, more students in health science colleges demonstrated a positive attitude toward blood donation and reported seeing calls for donation on social media. In addition, more students in health science colleges reported positive attitudes towards their friends and universities. Conversely, the positive attitude towards blood donation from families was more prominent in the non-health science colleges group. All of these differences were found to be statistically significant ( p -value < 0.001), except for the difference in willingness to donate if the university organizes a donation campaign ( p -value = 0.5). Furthermore, students with a high level of knowledge were found to have a significantly more positive attitude towards blood donation than those with a low level of knowledge. The detailed results of the attitude section can be found in Tables 3 and 4 .

Blood donation practice

Regarding blood donation practice, only 22.7% of the participants had donated before, and 55% of them donated irregularly. A small fraction of the participants (18.1%) had engaged in voluntary blood donation, and only 11.6% had donated once. Most participants (85.4%) expressed their intention to donate blood. We compared the practices of health and non-health science college students and found no significant difference in the donor ratio ( p -value = 0.81). However, the differences in the frequency and type of donation were significant ( p -value = 0.022, 0.043, respectively). We also observed significant differences in all aspects of donation practice between students with high and low knowledge ( p -value < 0.001). Specifically, 34.6% of students with high knowledge had donated before, compared to only 17.9% of those with low knowledge. Moreover, 28.5% of the high-knowledge group, compared to only 13.9% of the low-knowledge group, practiced voluntary donation. Finally, 12.2% of the high-knowledge group had donated more than twice, compared to only 3.3% of the low-knowledge group. The detailed results of the practice section are presented in Tables 5 and 6 .

Characteristics of blood donors and non-donors

We observed a significant difference in the distribution of participants based on their blood donation status. Those who had donated at least once were classified as donors. A majority of the donors were males (65.1%), whereas most of the non-donors were females (71.5%). In terms of knowledge regarding blood donation, approximately 43% of the donors had a high level of knowledge compared to only 24.1% of the non-donors ( p -value < 0.001). However, the two groups had no significant difference based on college type (health or non-health science college), with a p -value of 0.8. We provided the details of the characteristics of blood donors and non-donors in Online Appendix S2.

Factors that motivate and hinder blood donation

Regarding motivating factors, most participants (66%) were motivated to donate due to a friend or family member in need, followed by public promotion (42%). While 39% of participants were motivated by the potential health benefits of donating, only 13% felt that a national disaster would motivate them to donate. The least motivating factor was religious belief, which only motivated 1% of participants. Regarding barriers to donation, 37% of participants reported not donating because no one had asked. Other reasons included medical ineligibility (33%), fear of pain, bleeding, or infection (18%), concerns that donation would negatively affect their health (18%), difficulty accessing donation centers (15%), and medical mistrust (14%). Lack of time was the least cited barrier to donation (0.3%). More detailed information on motivating and preventing factors can be found in Online Appendix S3 and Online Appendix S4.

Factors that influence blood donation knowledge

As indicated by the multivariate analysis, individuals aged > 20 years demonstrated notably higher odds of having a high level of knowledge compared to those aged ≤ 20 years (aOR 1.77, 95% CI 1.62–1.93, p  < 0.001). Additionally, students enrolled in private and international universities had higher odds of having a high level of knowledge compared to those in governmental universities (aOR: 1.19; 95% CI 1.09–1.30; p -value < 0.001 and aOR: 1.44; 95% CI 1.13–1.84; p -value = 0.003, respectively). In contrast, students in non-health science colleges had significantly lower odds of having a high level of knowledge than students in health science colleges (aOR: 0.36; 95% CI 0.32–0.39; p -value < 0.001); refer to Table 7 for details.

Factors that influence blood donation status

Investigating predictors of blood donation showed that participants aged > 20 years were significantly more likely to be blood donors compared to those ≤ 20 years, with aOR of 2.21 (95% CI 1.99–2.45, p  < 0.001). However, being female significantly reduced the odds of being a blood donor (aOR: 0.21; 95% CI 0.19–0.23; p -value < 0.001). Urban residence was associated with lower odds of donation status than rural residence in the univariate analysis (OR: 0.83, 95% CI 0.75–0.92, p  < 0.001). However, this association became non-significant in the multivariate analysis (aOR: 0.90, with a p -value of 0.061). Participants with a history of congenital or chronic diseases were less likely to have a positive donation status (aOR: 0.81, 95% CI 0.68–0.96, p  = 0.014). In addition, those having a low knowledge level had significantly lower odds of blood donation compared to those with high knowledge levels (aOR: 0.40, 95% CI 0.37–0.44, p  < 0.001), Table 8 .

We conducted a cross-sectional study using a self-administered survey to assess the knowledge, attitude, practice, motivators, and barriers to blood donation among 12606 university students from 16 countries. This sample size is much larger than previous similar studies 1 , 2 , 3 , 8 , 10 , 12 , 13 , 14 , 15 , 17 , 19 , 22 , 23 , 24 , 25 , 26 , 27 . University students are an essential population to investigate as potential blood donors. Our findings revealed a low level of knowledge and practice of blood donation among the participants, although they held a positive attitude toward it.

Knowledge level

Our study revealed that a low percentage (28.5%) of university students have good knowledge of blood donation, which is similar to studies from Spain and Portugal (30%) 1 but higher than in Iran (15.5%) 27 . In contrast, studies from India (57%) 17 and Saudi Arabia (60.2%) 14 reported higher knowledge levels. Nevertheless, a recent study from Saudi Arabia showed that only 3% of students had a high knowledge level, while 44.4% had moderate knowledge 8 . About 78.1% of our participants knew their blood type, similar to a study in Brazil (79.1%) 19 , while a higher percentage of students in Qatar knew such essential and critical information 13 .

Furthermore, our results showed that higher age was associated with a high knowledge level, which is consistent with previous studies 13 , 17 . This may be explained by the fact that individuals’ general knowledge and awareness increase with age. Additionally, students in their first year of university tend to be burdened with between, which could limit their ability to acquire additional knowledge. However, an Ethiopian study did not find a significant association between age and knowledge level regarding blood donation 3 .

Females also had higher knowledge levels compared to males, which is commonly found in previous studies 17 , 22 , 27 . According to an Ethiopian study, the correlation between gender and knowledge level regarding donation is prominent in health science students 3 . However, the study found no significant relationship between gender and knowledge level among non-health science students. Likewise, our study did not detect any significant association between gender and knowledge level among all university students. In contrast, a study conducted in Saudi Arabia showed that males had significantly higher levels of knowledge 8 .

The study found that students in health science colleges had significantly higher levels of knowledge (34.7%) than those in non-health science colleges (15.7%). This pattern is consistent with a study conducted in Ethiopia, where only 13.9% of non-health science students had good or adequate knowledge, while 79.4% of health science students had a good knowledge level 3 . A similar result was also reported in India 17 . These disparities in knowledge levels may be attributed to variable socioeconomic and cultural backgrounds and differences in the distribution of colleges in each study.

A majority of the participants in our study exhibited positive attitudes toward blood donation. Similar positive responses toward blood donation were reported in studies conducted in Saudi Arabia, Pakistan, and India 14 , 17 . In our study, 24.2% of participants had received education on blood donation, whereas around 30% of participants in a study conducted in Saudi Arabia had attended lectures on this topic 14 . These findings emphasize the necessity of organizing effective campaigns to encourage blood donation, particularly at the university and college levels. Our study indicated that 79.8% of participants would be willing to donate if the university organized such campaigns, while a study conducted in Saudi Arabia revealed that 84% of their participants expressed a similar willingness to donate 14 . Furthermore, the results of our study and the Saudi Arabian study 14 suggest that greater attention should be given to social and public media, as around 43.5% and 41% of our participants and Saudi participants, respectively, reported not having seen any calls for blood donation on these platforms.

The practice of blood donation

According to our findings, only 22.7% of participants had donated blood at least once. This rate is higher than what has been reported in Iran (10%) and Qatar (15%) 13 , 27 . However, other studies have shown a higher percentage of students with a history of blood donation, including Greece (24%) 23 , Ethiopia (27.2%) 3 , Spain (28.1%) 24 , Saudi Arabia (29%) 8 , Brazil (32.6%) 19 , Italy (34%) 12 , Canada (43.8%) 3 , China (50%) 2 , India (55%) 17 , and the United States (56%) 28 . In our study, most donors donated blood voluntarily, which is consistent with previous studies in Greece 23 and Saudi Arabia 14 .

Our findings suggest that age is significantly associated with blood donation status, with an increase in age resulting in a higher likelihood of donating blood. These results are consistent with previous research demonstrating that higher ages positively correlate with blood donation 2 , 8 , 13 , 17 . We observed that more donors (34.6%) had higher knowledge levels than those with low or inadequate knowledge levels (17.9%). Therefore, having a high knowledge level increases the likelihood of blood donation. Other studies have similarly found that donors tend to have higher knowledge levels than non-donors 2 , 8 , 12 . In contrast, a study conducted in Ethiopia found no significant association between knowledge level and donation status 3 . Interestingly, a study in India 17 reported that inadequate knowledge increased the odds of donation among their sample, which contradicts our findings. This discrepancy highlights the need for standardization and validation of information provided through initiatives, media, and educational curricula in schools and universities.

Our findings suggest that a significant association exists between gender and blood donation status, with a higher proportion of males (40.1%) being donors compared to females (12.5%). This gender disparity in blood donation is well-documented in studies from various countries 3 , 10 , 13 , 17 , 22 , 23 , 27 . In addition to previous research, our findings suggest that males are more likely to donate blood despite females having a higher knowledge level, indicating that knowledge is not always the sole factor influencing donation behavior. This trend may be partially explained by the fact that more women in low- and middle-income countries suffer from anemia, which can disqualify them from donating 17 , 25 . Additionally, cultural taboos affecting women can be a barrier to donation, although this may be less prevalent among university students due to their relatively high socioeconomic and educational status 10 . A systematic review identified that weight requirements and adverse effects such as dizziness could discourage women from donating, despite being more altruistic than men 29 . Therefore, females represent a significant potential pool of donors in developing countries, and addressing barriers to donation and improving their health status could increase participation in blood donation initiatives.

Our study found no significant association between the field of study (health vs. non-health) and blood donation, as the percentage of donors did not differ significantly between health and non-health science students, despite the significant difference in knowledge level. This finding is consistent with other studies showing that good knowledge does not always translate into donation behavior 8 . However, a study of young adults in Hong Kong, China, found that studying in health science or medical fields significantly increased the likelihood of donation 2 . Surprisingly, studies in India and Pakistan found that donation was more common among students in non-medical fields 10 , 17 . These results highlight the need to explore other factors that may encourage or discourage students from donating blood.

Although there were significant differences in knowledge levels among the different types of universities, our study found no significant difference in blood donation practice. This suggests that having good knowledge does not necessarily lead to good practice, and other factors may be at play. To our knowledge, this is the first study to examine the association between types of universities and blood donation practice or knowledge, and further research is needed to explore potential explanations for our findings.

Motivators for and barriers against donation

66% of participants would be willing to donate blood if a friend or family member needed it, while 44% would do so for public recognition. Helping others or altruism was the most frequently reported motivation for donation, which is consistent with studies from various regions 9 , 13 , 19 , 29 . Personal health benefit was the most commonly reported motivation for donation, with 39% of our population indicating they would donate because it is healthy for the donor. This may be attributed to insufficient awareness among the participants, most of whom were in their first or second year of study 22 . This highlights the need to increase altruistic behavior among university students, especially those young or in their first year.

In our study, the most frequently reported reason for not donating was “no one asked,” with 37% of participants citing this as a factor. Previous studies 10 , 13 , 17 have similarly found that the lack of opportunity, including not being asked, and fear of potential adverse effects during or after donation are common reasons for not donating. Additionally, 18% of our participants reported that fear of pain, infection, or other health complications after donation prevented them from donating. Another frequently reported reason among non-donors was the belief that they were medically ineligible or unfit for donation, which accounted for 33% of responses in our study. This could be partly due to insufficient knowledge about the health requirements for donation 10 . This reason was also the most commonly reported among non-donors in studies conducted in Saudi Arabia, Brazil, and Greece 8 , 19 , 23 .

While some previous studies have shown that the availability of mobile donation centers is a motivating factor for donation 13 , our study found that 15% of our student population has not donated due to the lack of accessible donation centers. This can increase the number of donors by providing more donation centers in convenient locations for these students. Medical mistrust was identified as a significant barrier to voluntary activities that involve direct contact with healthcare workers and policies 30 , and this was the case for approximately 14% of our participants. Notably, our study only included university students, which provides insight into the level of trust in healthcare institutions and policies in our region. This issue is particularly relevant for minority groups in each country and countries with low-quality healthcare systems 31 . This phenomenon may also be linked to the substandard level of governmental or public health services in numerous countries within the MENA region, indicating the urgent need for significant improvement 32 , 33 . We must be cautious when motivating students or the general population, as incentives or motivation without adequate awareness of the donation process and its health requirements may attract high-risk populations who may provide false information to receive the incentive. Additionally, extrinsic motivations may compromise the intrinsic motivations of donors, reducing their long-term desire to donate once the incentives are no longer available 11 .

Strengths and limitations

This study represents the first large-scale multicenter investigation of its kind in our geographical region. Our study included 12,606 students from 16 countries, mainly from the MENA region. Moreover, our team of collaborators made tremendous efforts to ensure that a representative sample was collected in each country. Prior studies had much smaller sample sizes, often limited to one or two countries, and focused solely on health science students or medical students. In contrast, our study included non-health science college students and students from various types of universities, including governmental, private, and international universities. This comprehensive approach provides extensive and valuable insights into healthcare regulations and policies and paves the way for future targeted studies. Our study explored motivators for and barriers against blood donation, whereas previous studies only assessed motivators among donors and barriers among non-donors. This novel approach provides a complete understanding of the factors influencing blood donation. In addition, our study provides up-to-date information about blood donation in our region and fills a significant gap in the literature that aids in healthcare regulations and policies and paves the way for future targeted studies. University students represent a vital sector of our community. If their issues are appropriately addressed, voluntary donations may be a reliable source of blood supply instead of replacement donations.

However, it is important to note that our study has some limitations. Firstly, we utilized a cross-sectional design with convenience and snowball sampling, where the collaborators distributed a self-administered questionnaire on social media platforms. This data collection method may be susceptible to social desirability bias, as some students may have reported unreal information due to the socially desirable nature of blood donation. Selection bias may have also occurred, as only those who could respond to the online survey participated, even though we provided a printed (manual) version for those who could not fill in the online form. Additionally, our sample may have oversampled students with good backgrounds and attitudes towards donation while under-sampling those who do not know or care about our topic. Since our study only included university students, who may have higher social, economic, and educational backgrounds than the rest of the population in some countries, our results may not be generalizable over the entire population. The low response rate of non-health science students could have also affected our results. Moreover, since we did not imply a longitudinal design, we could not assess actual future intentions. While we have made efforts to collect comprehensive data from 16 countries, variations in regulations pertaining to weight, volume, and blood donation during menstruation may introduce limitations to the generalizability of our findings. Future research could delve deeper into these regulatory variations to strengthen the reliability and applicability of findings on a global scale.

Based on this, we emphasize that the generalization of the study results could primarily apply to the countries involved in this study. This limitation arises from potential racial and demographic disparities across nations, which may impact the transferability of findings to other regions. This underscores the need for caution when extrapolating findings to populations with distinct racial and demographic profiles.

Recommendations

Additional interventions are required to improve knowledge and encourage blood donation among students. These initiatives should provide validated information on the importance, necessity, and requirements of donation and information about the actual rates of complications. Misconceptions, myths, and irrational fears should also be addressed. Health-science students can be crucial in increasing public awareness and promoting regular voluntary blood donation. They can effectively dispel social and cultural myths and unfounded fears 23 . Students with good knowledge and attitudes should be engaged in developing new and attractive recruitment methods. Public universities should incorporate essential community voluntary activities, such as blood donation, into their policies. Essential information about blood donation could also be incorporated into the curriculum of colleges, regardless of field or year of study 15 . More accessible or mobile donation centers should be provided in convenient locations for students who face transportation challenges, and extending the working hours of donation centers can be an option. Mobile applications for recruiting and retaining potential and previous blood donors could be an effective solution, but they may only be available in high-income countries with good infrastructure 13 . Social mobile applications such as WhatsApp could creatively bridge the gap between donors, blood banks, and patients needing blood 34 .

Conclusions

Our study findings indicate that university students demonstrate a notable lack of knowledge about blood donation. Health science students, however, tend to exhibit higher levels of awareness than those studying in non-health science disciplines. Despite displaying generally positive attitudes towards blood donation, the actual donation rates among students are low, with negligible differences between health and non-health science students. Therefore, implementing targeted educational campaigns and improving accessibility to blood donation opportunities are imperative to cultivate a culture of blood donation within the university student population.

Data availability

All data relevant to the study are included in the article or uploaded as supplemental information.

Martínez-Santos, A. E. et al. Attitudes and knowledge in blood donation among nursing students: A cross-sectional study in Spain and Portugal. Nurse Educ. Today 106 , 105100 (2021).

Article   PubMed   Google Scholar  

Suen, L. K. P., Siu, J. Y. M., Lee, Y. M. & Chan, E. A. Knowledge level and motivation of Hong Kong young adults towards blood donation: A cross-sectional survey. BMJ Open 10 , e031865 (2020).

Article   PubMed   PubMed Central   Google Scholar  

Gebresilase, H. W., Fite, R. O. & Abeya, S. G. Knowledge, attitude and practice of students towards blood donation in Arsi university and Adama science and technology university: A comparative cross sectional study. BMC Hematol. 17 , 1–10 (2017).

Article   Google Scholar  

Ebada, M. A., Elmatboly, A. M. & Baligh, G. Intravenous oxytocin versus intramuscular oxytocin for the management of postpartum hemorrhage: A systematic review and meta-analysis. Curr. Drug Res. Rev. 12 , 150–157 (2021).

Allain, J. P. Current approaches to increase blood donations in resource-limited countries. Transfus. Med. 29 , 297–310 (2019).

Beyene, G. A. Voluntary blood donation knowledge, attitudes, and practices in central ethiopia. Int. J. Gen. Med. 13 , 67–76 (2020).

Myers, D. J. & Collins, R. A. Blood Donation. In Cambridge Handb. Psychol. Heal. Med. Second Ed. 567–569 (2023). doi: https://doi.org/10.1017/CBO9780511543579.128

Mahfouz, M. S. et al. Blood donation among university students: Practices, motivations, and barriers in Saudi Arabia. Avicenna J. Med. 11 , 70–76 (2021).

Mohammed, S. & Essel, H. B. Motivational factors for blood donation, potential barriers, and knowledge about blood donation in first-time and repeat blood donors. BMC Hematol. 18 , 1–9 (2018).

Anwe, M. O., Ul Fawwad, S. H., Anwer, S. & Ali, A. Attitude toward blood donation among medical and nonmedical students across Karachi. Asian J. Transfus. Sci. 10 , 113–117 (2016).

Chell, K., Davison, T. E., Masser, B. & Jensen, K. A systematic review of incentives in blood donation. Transfusion 58 , 242–254 (2018).

Cicolini, G. et al. Nursing students’ knowledge and attitudes of blood donation: A multicentre study. J. Clin. Nurs. 28 , 1829–1838 (2019).

Ibrahim, A. A., Koç, M. & Abdallah, A. M. Knowledge level, motivators and barriers of blood donation among students at Qatar university. Healthcare 9 , 1–12 (2021).

Alsalmi, M., Almalki, H., Alghamdi, A. & Aljasir, B. Knowledge, attitude and practice of blood donation among health professions students in Saudi Arabia; A cross-sectional study. J. Fam. Med. Prim. Care 8 , 2322 (2019).

Baig, M. et al. Knowledge, misconceptions and motivations towards blood donation among university students in Saudi Arabia. Pakistan J. Med. Sci. 29 , 1295–1299 (2013).

Google Scholar  

Alfouzan, N. Knowledge, attitudes, and motivations towards blood donation among King Abdulaziz Medical city population. Int. J. Family Med. 2014 , 1–8 (2014).

Raghuwanshi, B., Pehlajani, N. K. & Sinha, M. K. Voluntary blood donation among students - a cross-sectional study on knowledge and practice vs. Attitude. J. Clin. Diagn. Res. 10 , EC18–EC22 (2016).

PubMed   PubMed Central   Google Scholar  

von Elm, E. et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. J. Clin. Epidemiol. 61 , 344–349 (2008).

Zucoloto, M. L., Bueno-Silva, C. C., Ribeiro-Pizzo, L. B. & Martinez, E. Z. Knowledge, attitude and practice of blood donation and the role of religious beliefs among health sciences undergraduate students. Transfus. Apher. Sci. 59 , 102822 (2020).

World Medical Association. World Medical Association declaration of Helsinki: Ethical principles for medical research involving human subjects. Jama 310 , 2191–2194 (2013).

Abo Al-Shiekh, S. S., Ibrahim, M. A. & Alajerami, Y. S. Breast cancer knowledge and practice of breast self-examination among female university students, Gaza. ScientificWorldJournal 2021 , 1–7 (2021).

Javaeed, A. et al. Knowledge, attitude, and practice of blood donation among undergraduate medical students in Azad Kashmir. Cureus 12 , 1–9 (2020).

Papagiannis, D. et al. Blood donation knowledge and attitudes among undergraduate health science students: A cross-sectional study. Transfus. Apher. Sci. 54 , 303–308 (2016).

Martínez-Santos, A. E., Fernández-De-La-Iglesia, J. C., Casal-Otero, L., Pazos-Couselo, M. & Rodríguez-González, R. Blood donation attitudes and knowledge in Spanish undergraduates with roles in health-education. Transfus. Apher. Sci. 61 , 103416 (2022).

Batiha, A. M. & Albashtawy, M. Knowledge of Philadelphia University students regarding blood donation. Transfus. Med. 23 , 195–198 (2013).

Gomes, M. J., Nogueira, A. J., Antão, C. & Teixeira, C. Motivations and attitudes towards the act of blood donation among undergraduate health science students. Transfus. Apher. Sci. 58 , 147–151 (2019).

Majdabadi, H. A., Kahouei, M., Taslimi, S. & Langari, M. Awareness of and attitude towards blood donation in students at the Semnan University of Medical Sciences. Electron. Phys. 9 , 3592–3597 (2018).

Allerson, J. Assessment of Selected University Students’ Knowledge of Blood Donation and the Relationship with Intent to Donate Blood. [Master’s thesis, Minnesota State University, Mankato]. Cornerstone: A Collection of Scholarly and Creative Works for Minnesota State University, Mankato. (2012).

Bani, M. & Giussani, B. Gender differences in giving blood: A review of the literature. Blood Transfus. 8 , 278–287 (2010).

Mohottige, D. & Boulware, L. E. Trust in American medicine: A call to action for health care professionals. Hastings Cent. Rep. 50 , 27–29 (2020).

Spratling, R. & Lawrence, R. H. Facilitators and barriers to minority blood donations: A systematic review. Nurs. Res. 68 , 218–226 (2019).

Mate, K., Bryan, C., Deen, N. & McCall, J. Review of health systems of the middle east and North Africa Region. Int. Encycl. Public Health https://doi.org/10.1016/B978-0-12-803678-5.00303-9 (2016).

Katoue, M. G., Cerda, A. A., García, L. Y. & Jakovljevic, M. Healthcare system development in the Middle East and North Africa region: Challenges, endeavors and prospective opportunities. Front. Public Heal. 10 , 1045739 (2022).

Al-Hajri, Q. R. et al. The impact of whatsapp on the blood donation process in Saudi Arabia. J. Blood Med. 12 , 1003–1010 (2021).

Download references

Acknowledgements

The study authors gratefully acknowledge Dr. Mahmoud A. Ebada, Mentor of the Publishing Process at the EARG Group, for his diligent supervision of the writing process and invaluable editing contributions. All authors sincerely thank the study collaborators and representatives from various countries whose tireless efforts have been instrumental in realizing this comprehensive cross-sectional paper. Also, we extend our heartfelt appreciation to the study participants for their invaluable contribution of time and patience.

Country-specific team leaders

Algeria: Mohammed Amir Rais; Bahrain: Mohamed Ebrahim Abdulhusain; Egypt: Mohamed Elbahnasawy; Ghana: Justice Kwadwo Turzin; India: Romana Riyaz; Iraq: Halmat Subhi Sulaiman, Mareb H. Ahmed; Jordan: Layan Majed Daghash; Libya: Ekram Hasanin; Morocco: Narjiss Aji; Pakistan: Hassan Mumtaz, Amna Liaquat; Palestine: Mariam B Moghari, Abdelrhman Muwafaq Janem, Haya Hammad; Saudi Arabia: Nidaa T Alhumaidi; Sudan: Munira Dawod Alla Jabo, Arwa Hussein Bilil Ahmed; Syria: Moath Salem; Turkey: Ali Osman Balkan; Yemen: Moath Ahmed Al-Mekhlafi.

Ethical approval granting

Algeria: Mohammed Amir Rais; Egypt: Mohamed Elbahnasawy; India: Romana Riyaz; Iraq: Halmat Subhi Sulaiman, Mareb H.Ahmed; Libya: Ekram Hasanin; Pakistan: Hassan Mumtaz, Amna Liaquat; Palestine: Mariam B Moghari, Abdelrhman Muwafaq Janem; Saudi Arabia: Nidaa T Alhumaidi; Sudan: Munira Dawod Alla Jabo, Arwa Hussein Bilil Ahmed; Syria: Moath Salem; Yemen: Moath Ahmed Al-Mekhlafi.

Collaborators

Firas Aborigiba; Maya Mohamed Ali; Afrah Humaidan Sulaiman; Abdulrahman Allahham; Abdulghani Ahmed Al-Aswadi; Maab Saifaldin Mohammed Alzain; Osama Al Horani; Yosra Hussein Abo El-Azm; Mahmoud Alballa Almahdi; Malak Ramadan Elba; Esraa Mohamed Zedan; Ishmael Yaala; Adnan Alswiti; Zaid Hamdan; Khaled Saifullah; Israa Al-fayyadh; Zainab Khalid Abdulmutalab; Reem Chebli; Hale Betül Gönül; Jaasira Ansari; Zahra Ali Mohamed; Nawal Mahboob Basha; Alina Sami Khan; Fatima Amatur Raheem; Rasha Ashraf Alwredat; Assia Salah; Raneem El-Faouri; Khlood Saleh Al-Ansi; Ahmad Othman; Zainab Ali Shaker Hasan; Albaraa Muad Alshargabi; Musab Bouhajra; Idris Sula; Nasreen Ahmad Faq Ali; Hamza Faida; Meryem Ertuğrul; Hassan Aboul-Ella; Jarjees A. Sulaiman; Nadir Emre Herdan; Soumia Haddoubenderbal; Djedidi Lamis; Emmanuel Boateng Agyenim; Mohammed Abdul Kabir; Qassim ali; Mostafa Barakat; Shehab Mahdi AL-Ariqi; Eman Fayez Aljazzar; Fatema Abdulwahed Hasan; Kelvin Yeboah; Sarah saleh mohamed; Sahar Elazab Ahmed; Sulemana Mohammed; Abubakar Nazir; Abrar AbuHamdia; Joyous Ocran; Manar Hasan; Ikram Khabab; Mohamed Mostafa Mohamed; Ateeba Kamran; Belmegharbi Rania; Abdulrhman Alkhaled; Mohammad Hasan.

Author information

These authors contributed equally: Nael Kamel Eltewacy, Hossam Tharwat Ali and Mahmoud A. Ebada.

A list of authors and their affiliations appears at the end of the paper.

Authors and Affiliations

École Normale Supérieure Paris-Saclay, 91190, Gif-sur-Yvette, France

Nael Kamel Eltewacy

Eltewacy Arab Research Group (EARG), Cairo, Egypt

Nael Kamel Eltewacy, Hossam Tharwat Ali & Tarek A. Owais

Qena Faculty of Medicine, South Valley University, Qena, Egypt

Hossam Tharwat Ali, Mostafa Barakat & Mohamed Mostafa Mohamed

Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt

Tarek A. Owais

Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt

Souad Alkanj, Yosra Hussein Abo El-Azm & Mahmoud A. Ebada

Egyptian Fellowship of Neurology, Ministry of Health and Population of Egypt, Cairo, Egypt

Mahmoud A. Ebada

Emergency Medicine and Traumatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt

• Mohamed Elbahnasawy

Karary University, Omdurman, Sudan

Arwa Hussein Bilil Ahmed

Alnoor University College, Mosul, Iraq

Mareb H. Ahmed

Central Park Medical College, Lahore, Pakistan

Amna Liaquat

Faculty of Medicine, University of Tripoli, Tripoli, Libya

Ekram Hasanin & Firas Aborigiba

Al-Azhar University Gaza (AUG), Gaza, Palestine

Mariam B. Moghari

Alzaiem Alazhari University (AAU), Khartoum, Sudan

Munira Dawod Alla jabo, Maab Saifaldin Mohammed Alzain & Mahmoud Alballa Almahdi

Faculty of Pharmacy, Taif University, Taif, Saudi Arabia

Nidaa T. Alhumaidi

Faculty of Medicine, Al Quds University, Jerusalem, Palestine

Abdelrhman Muwafaq Janem

College of Medicine, University of Duhok, Duhok, Iraq

Halmat subhi sulaiman & Jarjees A. Sulaiman

Faculty of Medicine of Algiers1, University of Algiers1, Algiers, Algeria

Mohammed Amir Rais

Department of General Medicine, Shadan Institute of Medical Sciences, Hyderabad, Telangana, India

Romana Riyaz, Khaled Saifullah, Jaasira Ansari, Nawal Mahboob Basha, Fatima Amatur Raheem & Mohammed Abdul Kabir

Faculty of Medicine, Damascus University, Damascus, Syria

Moath Salem, Osama Al Horani & Ahmad Othman

Faculty of Medicine, Thamar University, Dhamar, Yemen

Moath Ahmed Al-Mekhlafi

Maroof International Hospital, Islamabad, Pakistan

Hassan Mumtaz

Faculty of Medicine, Bezmialem University, Istanbul, Turkey

Ali Osman Balkan & Hale Betül Gönül

Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco

Narjiss Aji

Islamic University of Gaza, Gaza, Palestine

Haya Hammad

The Hashemite University, Zarqa, Jordan

Layan Majed Daghash, Adnan Alswiti & Zaid Hamdan

Kasr Alainy Medical School, Cairo University, Giza, Egypt

Mohamed Ebrahim Abdulhusain, Zahra Ali Mohamed, Qassim Ali & Fatema Abdulwahed Hasan

Department of Biomedical Science, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana

Justice Kwadwo Turzin & Ishmael Yaala

Faculty of Medicine, Aleppo University, Aleppo, Syria

Maya Mohamed Ali

Faculty of Medicine, University of Khartoum, Khartoum, Sudan

Afrah Humaidan Sulaiman

College of Medicine, Sulaiman Alrajhi University, Albukayriah, Al-Qassim, Saudi Arabia

Abdulrahman Allahham & Albaraa Muad Alshargabi

Faculty of Medicine and Health Sciences, Sana’a University, Sanaa, Yemen

Abdulghani Ahmed Al-Aswadi

Stemosis Association for Scientific Research, Damascus, Syria

Osama Al Horani

Faculty of Medical Technology, University of Tripoli, Tripoli, Libya

Malak Ramadan Elba

Faculty of Medicine, Al-Azhar University in Cairo, Cairo, Egypt

Esraa Mohamed Zedan

University of Jordan, Amman, Jordan

Israa Al-fayyadh

Almughtaribeen University, Khartoum, Sudan

Zainab Khalid Abdulmutalab

University of Mohammed V of Health Sciences, Rabat, Morocco

Reem Chebli

Liaquat National Hospital and Medical College, Karachi, Pakistan

Alina Sami Khan

Hashemite University, Zarqa, Jordan

Rasha Ashraf Alwredat

Faculty of Medicine, Algiers University, Algiers, Algeria

Assia Salah

General Surgery Department, Hashemite Universit, Zarqa, Jordan

Raneem El-Faouri

21 September University of Medical and Applied Science, Boston, USA

Khlood Saleh Al-Ansi

Faculty of Medicine, MMMP, Mansoura University, Mansoura, Egypt

Zainab Ali Shaker Hasan

Faculty of Medicine and Pharmacy of Rabat, Rabat, Morocco

Musab Bouhajra & Hamza Faida

College of Applied Sciences, Sulaiman Al Rajhi University, Bukayriah, Al Qassim, Saudi Arabia

College of Medicine, University of Zakho, Zakho, Iraq

Nasreen ahmad faq ali

Medical School, İstanbul University, Istanbul, Turkey

Meryem Ertuğrul

Faculty of Veterinary Medicine, Cairo University, Giza, Egypt

Hassan Aboul-Ella

Bezmialem Vakif University, Istanbul, Turkey

Nadir Emre Herdan

University Abu Bekr Belkaid—TLEMCEN, Tlemcen, Algeria

Soumia Haddoubenderbal

Faculty of Medecine, University of Constantine 3, El Khroub, Algeria

Djedidi Lamis

University of Cape Coast, Cape Coast, Ghana

Emmanuel Boateng Agyenim, Kelvin Yeboah & Joyous Ocran

University of Science and Technology, Yemen (UST), Aden, Yemen

Shehab Mahdi AL-Ariqi

Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine

Eman Fayez Aljazzar

Faculty of Public Relations and Media, University of Tripoli, Tripoli, Libya

Sarah Saleh Mohamed

Faculty of Pharmacy, South Valley University, Qena, Egypt

Sahar Elazab Ahmed

Department of Biomedical Science, The University of Cape Coast, Cape Coast, Ghana

Sulemana Mohammed

King Edward Medical University, Lahore, Pakistan

Abubakar Nazir

Department of Medical Laboratory Science, Faculty of Medicine and Health Science, An-Najah National University, Nablus, Palestine

Abrar AbuHamdia

King Hamad University Hospital, Al Sayh, Bahrain

Manar Hasan

Faculty of Medicine, University of Badji Mokhtar Annaba, Annaba, Algeria

Ikram Khabab

Karachi Medical and Dental College, Karachi, Pakistan

Ateeba Kamran

Annaba, Algeria

Belmegharbi Rania

Faculty of Dentistry, Tishreen University, Lattakia, Syria

Abdulrhman Alkhaled

Aga Khan University Hospital, Nairobi, Kenya

Mohammad Hasan

You can also search for this author in PubMed   Google Scholar

EARG Collaborators

• , Arwa Hussein Bilil Ahmed
• , Mareb H. Ahmed
• , Amna Liaquat
• , Ekram Hasanin
• , Mariam B. Moghari
• , Munira Dawod Alla jabo
• , Nidaa T. Alhumaidi
• , Abdelrhman Muwafaq Janem
• , Halmat subhi sulaiman
• , Mohammed Amir Rais
• , Romana Riyaz
• , Moath Salem
• , Moath Ahmed Al-Mekhlafi
• , Hassan Mumtaz
• , Ali Osman Balkan
• , Narjiss Aji
• , Haya Hammad
• , Layan Majed Daghash
• , Mohamed Ebrahim Abdulhusain
• , Justice Kwadwo Turzin
• , Firas Aborigiba
• , Maya Mohamed Ali
• , Afrah Humaidan Sulaiman
• , Abdulrahman Allahham
• , Abdulghani Ahmed Al-Aswadi
• , Maab Saifaldin Mohammed Alzain
• , Osama Al Horani
• , Yosra Hussein Abo El-Azm
• , Mahmoud Alballa Almahdi
• , Malak Ramadan Elba
• , Esraa Mohamed Zedan
• , Ishmael Yaala
• , Adnan Alswiti
• , Zaid Hamdan
• , Khaled Saifullah
• , Israa Al-fayyadh
• , Zainab Khalid Abdulmutalab
• , Reem Chebli
• , Hale Betül Gönül
• , Jaasira Ansari
• , Zahra Ali Mohamed
• , Nawal Mahboob Basha
• , Alina Sami Khan
• , Fatima Amatur Raheem
• , Rasha Ashraf Alwredat
• , Assia Salah
• , Raneem El-Faouri
• , Khlood Saleh Al-Ansi
• , Ahmad Othman
• , Zainab Ali Shaker Hasan
• , Albaraa Muad Alshargabi
• , Musab Bouhajra
• , Idris Sula
• , Nasreen ahmad faq ali
• , Hamza Faida
• , Meryem Ertuğrul
• , Hassan Aboul-Ella
• , Jarjees A. Sulaiman
• , Nadir Emre Herdan
• , Soumia Haddoubenderbal
• , Djedidi Lamis
• , Emmanuel Boateng Agyenim
• , Mohammed Abdul Kabir
• , Qassim Ali
• , Mostafa Barakat
• , Shehab Mahdi AL-Ariqi
• , Eman Fayez Aljazzar
• , Fatema Abdulwahed Hasan
• , Kelvin Yeboah
• , Sarah Saleh Mohamed
• , Sahar Elazab Ahmed
• , Sulemana Mohammed
• , Abubakar Nazir
• , Abrar AbuHamdia
• , Joyous Ocran
• , Manar Hasan
• , Ikram Khabab
• , Mohamed Mostafa Mohamed
• , Ateeba Kamran
• , Belmegharbi Rania
• , Abdulrhman Alkhaled
•  & Mohammad Hasan

Contributions

HTA contributed to the conceptualization, validation, and supervision of data collection, as well as the writing of the original draft. NKE was involved in the conceptualization and validation. TAQ conducted data analysis and interpretation and contributed to the writing of the original draft. SA participated in writing the original draft and presenting the manuscript. The EC group contributed to the data collection. MAE provided guidance and oversight during the data analysis process, supervised the writing of the initial draft, and conducted extensive editing of the manuscript for intellectual errors. All authors reviewed and approved the current version of the manuscript.

Corresponding author

Correspondence to Mahmoud A. Ebada .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary information., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Eltewacy, N.K., Ali, H.T., Owais, T.A. et al. Unveiling blood donation knowledge, attitude, and practices among 12,606 university students: a cross-sectional study across 16 countries. Sci Rep 14 , 8219 (2024). https://doi.org/10.1038/s41598-024-58284-4

Download citation

Received : 18 October 2023

Accepted : 27 March 2024

Published : 08 April 2024

DOI : https://doi.org/10.1038/s41598-024-58284-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Blood donation
• University students
• Multinational
• Cross-sectional study

By submitting a comment you agree to abide by our Terms and Community Guidelines . If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing: Cancer newsletter — what matters in cancer research, free to your inbox weekly.

• Print this article

Attracting Donors to Your Academic Library

• DOI: 10.21061/valib.v57i1.1146
• Published on 1 Apr 2011

Author First, Quality First

The Importance of Abstracts in Research Papers: A Quick Guide

A research abstract, which provides a page-long summary of your research paper, is a very important part of your paper. The abstract is often the first thing that readers see about your research paper. Readers use the abstract to determine whether it’s relevant to their own research and understand the key findings. Let’s find out the purpose of a research paper abstract, how to write a good one, and why they’re so important for ensuring your publication success.

What is a Research Paper Abstract?

A research paper abstract provides readers with a short summary of your research paper. You can think of your research paper abstract as a kind of “elevator pitch” for your paper. Why did you write this research paper? What was your methodology? What did you find? Why are your findings important? If your research paper abstract is well written, readers will easily be able to understand what your paper is about and how it fits into the overall trend of research on your topic. Other researchers investigating your topic will be able to read your research paper abstract and learn whether your work is relevant to their own. This is why it is important to include the main keywords from your paper in the abstract. In addition, databases will use these keywords when they index your paper, so choose carefully!

A research paper abstract should always be short. The typical length is no more than 300 words; some journals demand shorter paper abstracts. The information contained in your abstract might vary a little bit depending on your field of research or the requirements of the journal (if you write a journal paper abstract). For example, the abstract for a research paper written in the social sciences might focus on providing a clear summary of the topic. In contrast, a scientific abstract is likely to heavily feature data, such as numbers and figures. The key to writing a good research paper abstract is to know what is common in your field of research so you can write what your readers are looking for.

What Kind of Research Paper Abstract Should I Write?

Unsurprisingly, given the variation in styles of research between different fields, there are different types of abstracts. The type of abstract you should write for your research paper will depend on the journal requirements, your field of research, or, if you’re a student, your professor’s or school’s requests. Let’s take a look at the different types of abstracts so you can figure out which one is right for your paper.

• Structured Abstracts A structured abstract is divided into distinct sections: objectives, methodology, results, and conclusion. Scientific abstracts are usually structured; so are research paper abstracts for papers in the medical field.
• Unstructured Abstracts Unstructured abstracts contain the same information that structured abstracts contain. The difference is in the presentation: unstructured abstracts are written as one long paragraph rather than being divided into clear sections.
• Informative Abstracts Informative abstracts are increasing in popularity. In an informative abstract, the author includes the key arguments, research outcomes, study population and methodology, and conclusions. Informative abstracts are written with more of a narrative flow compared to traditional unstructured abstracts and tend to be longer.
• Descriptive Abstracts Descriptive abstracts describe the information in a research paper. It does not provide a clear research outcome or conclusion or offer definitive arguments. Instead, descriptive abstracts talk about key concepts that are explored and explain the objective of the paper and the scope of the study. This type of abstract doesn’t provide too much detail and is often short.

No matter what kind of abstract you write, remember that your goal is to help readers understand what your paper is about in a snapshot. Whether your abstract is structured or unstructured, descriptive or informative, you should keep it brief, include keywords, and highlight the most important parts of your article including the objective and any conclusions or key arguments made.

Tips for Writing a Great Abstract

Now that you know the importance of writing a great research paper abstract, it’s time to figure out how to do it! There are a couple of tips you can keep in mind when writing a research paper abstract to make sure your abstract is effective. First, even though the abstract is the first thing most readers will encounter about your paper, it should be the last thing you write. Many researchers make the error of writing their abstract early on in the writing process. But as any experienced researcher knows, papers often change as you write them. Results are surprising, data gets reinterpreted, and the key arguments change as new information comes to light. If you write your abstract before you have finished your paper, you will end up rewriting it multiple times.

Second, don’t make your abstract too long or too short. Again, most journals have requirements that you should follow. Make sure you include all of the important information and keywords in your abstract so that nothing is left out. Ask a friend to read your abstract and tell you what they think the paper is about. Having another set of eyes is always helpful.

Finally, if you’re struggling, seek out an abstract writing service like the one offered by Enago. It’s not plagiarism or cheating to have someone else write your abstract—it can offer you a great advantage as they help you identify the main ideas and arguments. Like using an editing service, an abstract writing service can give your research paper the extra boost it needs to make it to the next level and get published.

Whether you write your own research paper abstract or use a service, one thing is for sure - your research paper needs a good abstract! So don’t delay: use these tips to make sure you have a fantastic research paper abstract.

Our English Editing Services

Top Impact Scientific Editing New

Top Impact Scientific Editing Service offers in-depth scientific and developmental

Substantive Editing Popular

Substantive Editing, our popular flagship service, is specifically tailored for quality.

Copy Editing

Our professional Copy Editing service is designed for quality-conscious authors.

Our Experts

Similar Articles

7 Proven Strategies to Proofread Effectively

How are Editing, Copy Editing & Proofreading Different?

Editing vs. Copyediting: What's the Difference?

What Are The Different Types of Book Editing?

What Are the Steps in Editing a Document?

Substantive Editing vs. Copyediting: What's the Difference?

Why Copy Editing is Important

A Step-by-Step Guide to Journal Editing

We use cookies to offer you a personalized experience. By continuing to use this website, you consent to the use of cookies in accordance with our Cookie Policy.

Cultural Relativity and Acceptance of Embryonic Stem Cell Research

Article sidebar.

Main Article Content

There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole . Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus. [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

[1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk ; Kimmelman, J., Hyun, I., Benvenisty, N.  et al.  Policy: Global standards for stem-cell research.  Nature   533 , 311–313 (2016). https://doi.org/10.1038/533311a

[4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk

[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research.  The New England journal of medicine ,  351 (3), 207–209. https://doi.org/10.1056/NEJMp048145 ; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos . The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos ; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy , 38 (2/3), 264–284. http://www.jstor.org/stable/24439776 ; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells.  The New England journal of medicine ,  351 (3), 209–211. https://doi.org/10.1056/NEJMp048147 ; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality.  Bosnian journal of basic medical sciences ,  4 (1), 5–14. https://doi.org/10.17305/bjbms.2004.3453

[6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review.  Restorative neurology and neuroscience ,  28 (4), 589–603. https://doi.org/10.3233/RNN-2010-0543

[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

[25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech.

[26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA.  Reproductive biomedicine online ,  18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa.  Clinical trials (London, England) ,  3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M.  Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity.  Research Ethics ,  14 (3), 1-17.  https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

Article Details

This work is licensed under a Creative Commons Attribution 4.0 International License .

• Download PDF
• Share X Facebook Email LinkedIn
• Permissions

Exploring and Reducing the Impact of Neighborhoods on Health Disparities

• 1 Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
• 2 Medical College of Wisconsin, Milwaukee
• Original Investigation Neighborhood Determinants and Symptom Severity Among Individuals With Psychosis Oladunni Oluwoye, PhD; Megan Puzia, MS; Ari Lissau, BA; Ofer Amram, PhD; Douglas L. Weeks, PhD JAMA Network Open

Health is a complex construct, the consequence of an interplay of a myriad of factors—some known (smoking, exercise, diet, and stress), but most unknown. Health care professionals are motivated to help patients live long, healthy, happy lives. However, the root causes of good health have remained stubbornly elusive. Historically, clinicians have focused on diagnosing and controlling disease, achieving specific targets such as blood pressure and blood glucose control, preventing unhealthy complications, and minimizing devastating outcomes. However, this has not always led to good health; more factors are at play. In addition to expected variances in health, there are striking disparities in health worldwide. Certain groups of people die younger and bear the brunt of poor outcomes. 1 For example, Black US residents have nearly double the rate of end-stage kidney disease and kidney-related deaths than White US residents. 2

Initially, clinicians were blamed for the disparate outcomes. 3 However, as the health care system tested interventions to reduce disparities, it became clear that factors not in control of the health care system contributed to health and health outcomes. There is a web of influences across multiple domains involving a dynamic interaction of genetics, behaviors, as well as sociocultural determinants. A good place to explore these factors is the neighborhood in which an individual resides. Important contributors to health, life circumstances, and social determinants of health cluster within neighborhoods. Assessing factors at the neighborhood level provides a more nuanced exploration of health outcome influences compared with assessing elements at the individual level. 4

Neighborhood characteristics—including racial and ethnic composition, environmental exposures, as well as the social and physical or built environments—are correlated with health outcomes and have been identified as important aspects to consider in research and clinical management. 4 , 5 Similarly, evidence has shown that socioeconomic status is associated with physical and social environments within neighborhoods and is a potential target for health intervention to reduce disparities. 5 Living in neighborhoods where there is concentrated poverty, poor educational and vocational opportunities, high unemployment rates, higher rates of crime and violence, limited or no access to healthy food options, and reduced greenspace all contribute to poor health and suboptimal outcomes.

Dr Oluwoye and colleagues 4 focus on neighborhood determinants of mental health, namely symptom severity among individuals with psychosis. They identified 3 types of neighborhoods as having disparate impacts on mental health: urban low-risk, urban high-risk, and rural. Urban low-risk neighborhoods had high income, educational attainment, and access to transportation and health care but also high levels of environmental exposures. Urban high-risk neighborhoods had low income and educational attainment and low access to health care with high access to transportation and environmental exposures. Rural areas had average income, average-to-low educational attainment, and limited access to health care and transportation but low levels of environmental exposure. In addition to well-established correlates of depression and anxiety, they found that urban high-risk neighborhoods had worse mental health compared with urban low-risk or rural areas. This finding is not surprising, given the challenges of day-to-day life that can occur in neighborhoods with higher risk profiles. For example, neighborhoods with high crime and gun violence cause chronic stress for those living there, a potent influencer of mental health. Furthermore, urban high-risk neighborhoods have decreased walkability, high pollution, poor food environments, inadequate recreational space for physical activity, high stress, low civic engagement, and decreased social connectedness. 5 , 6 Their conclusions supported the need for assessing and understanding the cumulative impact of neighborhood factors on health to improve health outcomes.

The important question is what can be done to minimize risks for poor health outcomes in neighborhoods with higher risk profiles and limited resources? Fifteen years ago, the World Health Organization stated that “the unequal distribution of health-damaging experiences is not in any sense a natural phenomenon but is the result of a toxic combination of poor social policies and programs, unfair economic arrangements, and bad politics.” 7 They outlined several steps that could close this gap: improve daily living conditions; tackle the inequitable distribution of power, money, and resources; measure and understand the problem; and assess the impact of action on reducing health disparities and improving health outcomes. These reforms are beyond the power of individual clinicians, requiring a collaborative effort between the individuals most impacted by neighborhood determinants, specialists in multiple disciplines, and interdisciplinary teams to reduce inequities in health and improve outcomes. However, closing the gap will likely require significant changes in sociopolitical, cultural, and economic systems, beyond the power of the health care system.

Research to identify and address neighborhood influences on specific health consequences is an important step toward improving both mental and physical health outcomes. At present, most research on neighborhoods has been exploratory. 6 The harder task will be to design and evaluate the impact of tailored neighborhood interventions on reducing disparities and improving outcomes that are specific to community needs. Research like that of Dr Oluwoye and colleagues 4 can help lay the groundwork for next steps.

Accepted for Publication: March 28, 2024.

Published: May 15, 2024. doi:10.1001/jamanetworkopen.2024.10206

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Jackson JL et al. JAMA Network Open .

Corresponding Author: Jeffrey L. Jackson, MD, MPH, Medical College of Wisconsin, 5000 W National Ave, Milwaukee WI 53295 ( [email protected] ).

Conflict of Interest Disclosures: None reported.

See More About

Jackson JL , Williams JS. Exploring and Reducing the Impact of Neighborhoods on Health Disparities. JAMA Netw Open. 2024;7(5):e2410206. doi:10.1001/jamanetworkopen.2024.10206

Manage citations:

© 2024

Select Your Interests

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Get the latest research based on your areas of interest.

Others also liked.

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

• Open access
• Published: 13 May 2024

Organ donation after extracorporeal cardiopulmonary resuscitation: a nationwide retrospective cohort study

• Tetsuya Yumoto 1 ,
• Kohei Tsukahara 1 ,
• Takafumi Obara 1 ,
• Takashi Hongo 1 ,
• Tsuyoshi Nojima 1 ,
• Hiromichi Naito 1 &
• Atsunori Nakao 1  

Critical Care volume  28 , Article number:  160 ( 2024 ) Cite this article

454 Accesses

6 Altmetric

Metrics details

Limited data are available on organ donation practices and recipient outcomes, particularly when comparing donors who experienced cardiac arrest and received extracorporeal cardiopulmonary resuscitation (ECPR) followed by veno-arterial extracorporeal membrane oxygenation (ECMO) decannulation, versus those who experienced cardiac arrest without receiving ECPR. This study aims to explore organ donation practices and outcomes post-ECPR to enhance our understanding of the donation potential after cardiac arrest.

We conducted a nationwide retrospective cohort study using data from the Japan Organ Transplant Network database, covering all deceased organ donors between July 17, 2010, and August 31, 2022. We included donors who experienced at least one episode of cardiac arrest. During the study period, patients undergoing ECMO treatment were not eligible for a legal diagnosis of brain death. We compared the timeframes associated with each donor’s management and the long-term graft outcomes of recipients between ECPR and non-ECPR groups.

Among 370 brain death donors with an episode of cardiac arrest, 26 (7.0%) received ECPR and 344 (93.0%) did not; the majority were due to out-of-hospital cardiac arrests. The median duration of veno-arterial ECMO support after ECPR was 3 days. Patients in the ECPR group had significantly longer intervals from admission to organ procurement compared to those not receiving ECPR (13 vs. 9 days, P  = 0.005). Lung graft survival rates were significantly lower in the ECPR group (log-rank test P  = 0.009), with no significant differences in other organ graft survival rates. Of 160 circulatory death donors with an episode of cardiac arrest, 27 (16.9%) received ECPR and 133 (83.1%) did not. Time intervals from admission to organ procurement following circulatory death and graft survival showed no significant differences between ECPR and non-ECPR groups. The number of organs donated was similar between the ECPR and non-ECPR groups, regardless of brain or circulatory death.

Conclusions

This nationwide study reveals that lung graft survival was lower in recipients from ECPR-treated donors, highlighting the need for targeted research and protocol adjustments in post-ECPR organ donation.

A worldwide crisis in organ shortage is intensifying as the need for transplantations spikes; however, the supply of available organs falls short of meeting this escalating demand, further widening the gap between those in need and the organs available [ 1 ]. In response, the significance of comprehensive screening for brain death in the intensive care unit (ICU), particularly following cardiac arrest, to identify potential organ donors has been increasingly emphasized [ 2 , 3 ].

Extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) has been increasingly employed as an emerging rescue treatment strategy [ 4 , 5 ]. However, the implementation of ECPR introduces complex ethical challenges, primarily because it frequently results in patients being placed on mechanical support with minimal prospects of neurological recovery [ 6 ]. Previous research has indicated that patients resuscitated with ECPR exhibit a markedly higher rate of brain death compared to those who undergo conventional CPR [ 2 ]. Indeed, a large retrospective study of ECPR in Japan, a leading country in the field of ECPR, revealed that decisions to withhold or withdraw life-sustaining therapy were most frequently made on the first day, with a median decision time of 2 days following admission to the ICU. Importantly, the perceived unfavorable neurological prognosis was the primary reason for the withhold or withdraw life-sustaining therapy decision [ 7 ]. In Japan, the legal diagnosis of brain death while on extracorporeal membrane oxygenation (ECMO) was not allowed until recent guideline amendments [ 8 ]. Further, the actual practice patterns and prevalence of organ donation following ECMO discontinuation have not been thoroughly investigated. A registry study from Europe suggests that organ donation rates are higher in patients undergoing ECPR than those receiving conventional CPR, indicating a potential for increasing organ donations through ECPR [ 9 , 10 ].

This situation highlights the need for a comprehensive investigation into the practices of organ donation following ECPR, encompassing donor characteristics and the impact on recipients. To date, there has been a lack of research focused on the outcomes for recipients of organs from donors who have undergone ECPR, as well as those who have not. This study aims to fill this gap by examining the current practices and outcomes of organ donation post-ECPR, thereby enhancing our understanding of the potential for organ donation following cardiac arrest.

Study design and ethics

This was a nationwide retrospective cohort study in Japan using the Japan Organ Transplant Network database, covering the entire cohort of deceased organ donors of any ages, from July 17, 2010 through August 31, 2022. The Japan Organ Transplant Network prospectively collects data, including basic patient information and the clinical course details. These are recorded in a paper-based format by a transplant coordinator, based upon the patient’s medical records. This study was approved by the Ethics Committee of the Japan Organ Transplant Network (Approved Number: 15) and the Ethics Committee of Okayama University Hospital (Approved Number: K2303-030). Informed consent from the patient's family or legal representative was waived in this study.

Organ donation policy in Japan

The history and details of organ donation policy and the surrounding system are elaborated on elsewhere [ 11 , 12 ]. To summarize, Japan's organ donation policy after brain death underwent significant revision with the implementation of the revised Organ Transplant Law on July 17, 2010. This revision introduced two major changes: firstly, it established a system permitting organ donation with only the family's consent when the preferences of the deceased are unknown; and secondly, it authorized the transplantation of organs from children under 15 years of age. Prior to these changes, organ donation after brain death was permitted only if the patient had formally documented their wish to donate their organs. As a direct consequence of these policy revisions, the number of organ transplants from brain-dead donors saw a substantial increase, from 86 cases recorded between 1997 and 2010 to 413 cases between 2010 and 2017. In Japan, the donor's family has the right to choose which organs can be procured for recipients.

Protocol for organ donation following brain death

The timing of presenting organ donation as a potential end-of-life care option is entirely at the discretion of the attending physician or according to hospital policy. Per the Japan Organ Transplant Network procedures, this option is typically presented after the clinical confirmation of brain death. However, if a patient is considered a potential organ donor due to devastating brain damage, the presentation of this option can proceed before the confirmation of brain death. Upon family consent, the process requires two distinct legal confirmations of brain death, conducted at least 6 h apart (or 24 h for children under 6 years old), through comprehensive neurological tests, an apnea test, and electroencephalography, leading to the eventual retrieval of organs. Previously, during the study period, individuals undergoing ECMO treatment were not eligible for a legal diagnosis of brain death until the guidelines were updated on January 1, 2024. Therefore, during our study, brain death could only be diagnosed post-decannulation of veno-arterial (VA) ECMO, when possible. In Japan, the transfer of potential organ donors between hospitals for the purpose of donation is prohibited.

Protocol for organ donation following circulatory death

In Japan, controlled donation after circulatory death programs, particularly those using VA ECMO perfusion for organ preservation, have not been widely introduced [ 13 ]. Consequently, only kidneys and pancreases are typically donated after circulatory death under the scenario of unexpected circulatory demise. Accordingly, all donors after circulatory death have been categorized as IIb or VI, in accordance with the modified Maastricht classification [ 14 ]. The placement of a catheter for organ perfusion and the administration of heparin are permitted only after a diagnosis of brain death has been confirmed and the donor's family has consented to preoperative procedures. This allows for the placement of a catheter before cardiac arrest and the administration of heparin.

Study population and data extraction

The data source for this study was the Japan Organ Transplant Network database. We included all deceased organ donors from whom at least one organ was recovered and subsequently transplanted. From this cohort, we specifically selected those individuals who had experienced at least one episode of cardiac arrest either before or after hospital arrival were selected. This selection was based on the free text comments that summarized the clinical course from admission to the legal determination of brain death. We received the anonymized data as follows: whether the donation was after brain death or circulatory death, age, sex, primary disease or injury, the modified Maastricht classification for donation after circulatory death (either IIb or VI as mentioned above), time intervals from admission to brain death confirmation, presentation of the option for organ donation, legal determination of brain death, organ procurement, the number of organs donated, and, if applicable, the duration of VA ECMO use in patients who received ECPR. The matched data from donors and recipients, provided by the Japan Organ Transplant Network using identifiable numbers, were used to observe graft survival rates over the longest follow-up period.

The primary outcome was timeframe for the organ donation process, spanning from admission to organ procurement. Secondary outcomes included the number of organs donated and their graft survival rates.

Statistical analysis

Continuous data were expressed as medians with interquartile range (IQR), and categorical data as counts and percentages. Patients were stratified based on whether they underwent ECPR and the type of donation (either after brain death or circulatory death) for comparative analyses. Comparisons between the two groups employed the Mann–Whitney U test for continuous variables and the Chi-square test for categorical variables. Graft survival curves were generated using the Kaplan–Meier method and were compared with the log-rank test. Graft survival is defined as the graft still functioning and not having been rejected by the recipient's body at a specified time post-transplantation. This excludes cases where the patient has been relisted for transplantation. Specifically for kidney transplants, graft survival also includes the period until the patient becomes dependent on dialysis again. Donor and recipient characteristics were not matched between groups. In an exploratory analysis, as ECMO technology and management have developed over last years, graft survival rates except for small intestine were compared between the periods from 2010 to 2017 and 2018 to 2022. Missing data were removed during the analysis whenever comparisons were made. All tests were two-tailed, and a P value of < 0.05 was considered statistically significant. Analyses were conducted using Prism 10.0.3 (GraphPad, San Diego, CA) and IBM SPSS Statistics 26 (IBM SPSS, Chicago, IL).

During the study period, there were 370 donors after brain death with an episode of cardiac arrest, of which 26 (7.0%) patients received ECPR and 344 (93.0%) did not receive ECPR. Additionally, there were 160 donors after circulatory death, among whom 27 (16.9%) patients received ECPR and 133 (83.1%) did not.

Donation after brain death

Table 1 shows the demographic and clinical characteristics of donors after brain death with an episode of cardiac arrest, revealing similar basic demographics between groups. However, the majority of cases in the ECPR group were of cardiac origin. The median duration of VA ECMO support in the ECPR group was 3 days (IQR, 1 to 4). Compared to those not receiving ECPR, patients in the ECPR group experienced significantly longer intervals from admission to the presentation of the organ donation option to their families (5 vs. 3 days, P  = 0.012), to the clinical confirmation of brain death (9 vs. 5 days, P  = 0.001), and to organ procurement (13 vs. 9 days, P  = 0.005).

Table 2 presents the number and distribution of organs donated, comparing the ECPR and non-ECPR groups. The median number of organs donated was similar between the groups (5 vs. 5, P  = 0.294). The proportion of heart donations was significantly lower in the ECPR group compared to the non-ECPR group (50% vs. 80%, P  < 0.001). However, the donation rates for other organs were comparable between the two groups.

Figure  1 illustrates the graft survival curves for each organ. The lung graft survival rates were significantly lower in the ECPR group compared to the non-ECPR group (log-rank test P  = 0.009). Graft survival rates for both unilateral (single) and bilateral (double) lung grafts among recipients from brain-dead organ donors were generally lower in the ECPR group. This reduction was statistically significant for unilateral lung grafts, as detailed in Additional file 1 . No significant differences were observed in the graft survival rates of other organs.

The Kaplan–Meier curve of graft survival for each organ among recipients from brain-dead organ donors, comparing those who had received ECPR with those who had not. The P values obtained from the log-rank test for heart, lung, liver, pancreas, kidney, and small intestine were 0.072, 0.009, 0.950, 0.902, 0.577, and 0.519, respectively. The median observation periods for grafts from donors who experienced cardiac arrest and received ECPR versus those from non-ECPR donors, respectively, were as follows: for heart grafts, 1203 days (IQR: 542 to 2278) and 1690 days (IQR: 908 to 2610); for lung grafts, 777 days (IQR: 573 to 1816) and 1323 days (IQR: 596 to 2211); for liver grafts, 1816 days (IQR: 671 to 2438) and 1551 days (IQR: 738 to 2466); for pancreas grafts, 1083 days (IQR: 442 to 2118) and 1708 days (IQR: 677 to 2673); for kidney grafts from brain-dead donors, 1787 days (IQR: 736 to 2429) and 1690 days (IQR: 987 to 2576); and for small intestine grafts, 2446 days (IQR: 2446 to 2446) and 703 days (IQR: 404 to 1217); ECPR: extracorporeal cardiopulmonary resuscitation

Donation after circulatory death

Table 3 outlines the demographic and clinical characteristics of donors post-circulatory death, highlighting a higher prevalence of male donors in the ECPR group compared to the non-ECPR group. Regarding the primary disease or injury, cardiac diseases were notably more common among ECPR patients, mirroring the trend observed in brain-dead organ donors. The reporting of the duration of VA ECMO support was limited by extensive missing data. Additionally, the intervals from admission to offering the option of organ donation to the family and proceeding to organ procurement showed no significant differences between the two groups.

Table 4 reports the number and distribution of organs donated, comparing the ECPR and non-ECPR groups. The pancreas was not donated in either group. High kidney donation rates were noted in both groups. Left kidney donation was lower in the ECPR group compared to non-ECPR group (85 vs. 96%, P  = 0.023).

Figure  2 shows the graft survival curve for kidneys, indicating no significant differences between the ECPR and non-ECPR groups.

The Kaplan–Meier curve of graft survival for kidney among recipients from circulatory-dead organ donors, comparing those who had received ECPR with those who had not. The P values obtained from the log-rank test were 0.363. The median observation periods for grafts from donors who experienced cardiac arrest and received ECPR versus those from non-ECPR donors were 2071 days (IQR: 1004 to 3110) and 2160 days (IQR: 1175 to 3535), respectively. ECPR: extracorporeal cardiopulmonary resuscitation

Exploratory analysis

Lung graft survival rates for ECPR patients from the periods 2010–2017 and 2018–2022 showed no significant difference, as indicated in Additional file 2 (log-rank test P  = 0.827). Similarly, liver graft survival rates for the same periods did not differ significantly within the ECPR group; however, liver graft survival rates from ECPR patients were significantly lower compared to those from non-ECPR patients in 2018–2022 (log-rank test P  = 0.023). Comparable patterns were observed in graft survival for other organs.

In this nationwide cohort study conducted in Japan, we found that time intervals from admission to organ procurement after brain death were significantly longer for ECPR patients compared to non-ECPR patients. However, these intervals were similar following circulatory death. The number of organs donated after either brain death or circulatory death was comparable between the ECPR and non-ECPR groups. Despite similar proportions of lung donations between groups, lung graft survival was significantly lower in recipients from brain-dead organ donors who received ECPR compared to those without ECPR.

Our findings indicate that the time from admission to organ procurement in Japan is longer than that reported in other countries [ 15 , 16 ]. This variation may be attributed to the extensive discussions required around end-of-life care options, including organ donation, which are further complicated by the cultural emphasis on family involvement in medical decision-making processes [ 17 ]. Moreover, we noted that donors who underwent ECPR experienced longer delays to organ procurement compared to those who did not receive ECPR. This delay is likely due to legal constraints preventing the determination of brain death until after the decannulation of VA ECMO, highlighting a unique challenge in the organ donation process in Japan. Notably, guidelines were updated on January 1, 2024, allowing the diagnosis of brain death while on ECMO.

The influence of a donor’s ICU stay duration on recipient outcomes remains underexplored. A study from Germany indicated that the ICU stay duration of donors did not significantly impact the survival rates or outcomes following heart transplantation [ 18 ]. Similarly, another study concluded that the duration of a donor's ICU stay had no significant effect on patient and graft survival rates after pediatric liver transplantation [ 19 ]. These insights suggest that the ICU stay duration may not critically affect transplantation outcomes, consistent with our observations, with the possible exception of lung transplants. Meanwhile, there is limited data on donors who are brain dead with ongoing ECMO support. Among the available studies, the largest, conducted in France, focused predominantly on donors who received VA ECMO. It revealed that kidneys procured and transplanted from these donors did not exhibit differences in survival and functional outcomes compared to those from donors who were brain dead without ECMO support [ 20 ].

ECPR is typically administered to patients with a potential or presumed cardiac origin [ 4 , 5 ]. Consequently, even after the successful decannulation of VA ECMO, we observed a significantly lower rate of heart donations in the ECPR group compared to the non-ECPR group. Meanwhile, despite similar lung donation rates between groups, lung graft survival was significantly lower in ECPR recipients from brain-dead donors than in those without ECPR. This trend was consistent across both time periods, from 2010 to 2017 and from 2018 to 2022. This phenomenon may be attributable to “ECMO lung”, a condition characterized by lung injury induced by VA ECMO, resulting from inflammatory injury or pulmonary congestion [ 21 ]. Meanwhile, we observed that liver graft survival rates from ECPR patients were significantly lower compared to those from non-ECPR patients in 2018–2022. Although we could not fully explain the reasons, this might be partly due to severe cardiovascular condition affecting liver function through mechanisms such as cardiac hepatopathy, which includes impaired arterial perfusion and passive congestion from elevated venous pressure, often exacerbated by the hemodynamic instability and changes in liver perfusion associated with ECMO support [ 22 ].

According to the study using Japanese Diagnosis Procedure Combination Database, the prevalence of ECPR for OHCA from July 2010 to March 2017 was 2.6% (5612/212,295) [ 23 ]. Over the past 12 years, despite the lack of legal permission of brain death diagnosis during ECMO support, our study identified 53 deceased organ donors who had undergone VA ECMO due to at least one episode of cardiac arrest, with the vast majority experiencing OHCA. The exact number of brain death cases among patients who received ECPR for OHCA in the prior study is unknown; however, considering a meta-analysis indicating a 27.9% prevalence of brain death following ECPR [ 6 ], it can be speculated that the majority may have died without the opportunity for organ donation.

This study has several limitations. First, regarding donor characteristics, the study did not capture donors' comorbidities, the detailed processes involved in organ donation, or outcomes focused on the donors' families. Second, the analysis was limited by the absence of specific data, particularly the duration of VA ECMO support. These missing data restricted our ability to analyze and adjust graft survival outcomes in relation to the duration of ECMO support. Third, from the perspective of recipients, essential characteristics, including factors known to influence graft survival such as human leukocyte antigen mismatches and primary or underlying diseases, were unavailable. As a result, these variables were not adjusted for in our analysis [ 24 , 25 , 26 ]. Lastly, detailed recipient data was not available, and the small sample size precluded matching between groups, further constraining our analysis.

Despite these limitations, our research provides crucial insights into the patterns of organ donation and long-term graft survival after ECPR, based on extensive nationwide data. Although diagnosing brain death while on ECMO is now permitted in Japan, scenarios in which brain death is diagnosed after successful decannulation of ECMO are expected to increase as the use of ECPR as a strategy for OHCA expands worldwide. While the primary goal of ECPR should not be organ donation, our findings underline the necessity for additional research to develop thorough guidelines for end-of-life care and the organ donation process in such scenarios. Additionally, our study suggests that lung transplantation from donors who underwent ECPR may result in worse graft survival compared to those who did not receive ECPR. This aspect, as well as the impact on other organs, warrants further investigation in future research.

In this nationwide study from Japan, we discovered that lung graft survival was lower in recipients from ECPR-treated donors. These results emphasize the influence of ECPR on organ donation and underscore the need for further research to refine end-of-life care and organ donation protocols, particularly concerning lung graft survival and its effects on other organs following ECPR.

Availability of data and materials

Data not available due to ethical restrictions.

Abbreviations

• Extracorporeal membrane oxygenation

Extracorporeal cardiopulmonary resuscitation

Interquartile range

• Out-of-hospital cardiac arrest

Veno-arterial

Lewis A, Koukoura A, Tsianos GI, Gargavanis AA, Nielsen AA, Vassiliadis E. Organ donation in the US and Europe: the supply vs demand imbalance. Transpl Rev. 2021;35(2):100585. https://doi.org/10.1016/j.trre.2020.100585 .

Article   Google Scholar  

Sandroni C, D’Arrigo S, Callaway CW, et al. The rate of brain death and organ donation in patients resuscitated from cardiac arrest: a systematic review and meta-analysis. Intensive Care Med. 2016;42(11):1661–71. https://doi.org/10.1007/s00134-016-4549-3 .

Article   PubMed   PubMed Central   Google Scholar  

Morrison LJ, Sandroni C, Grunau B, et al. Organ donation after out-of-hospital cardiac arrest: a scientific statement from the international liaison committee on resuscitation. Circulation. 2023;148(10):E120–46. https://doi.org/10.1161/CIR.0000000000001125 .

Article   PubMed   Google Scholar  

Inoue A, Hifumi T, Sakamoto T, Kuroda Y. Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in adult patients. J Am Heart Assoc. 2020;9(7):1–12. https://doi.org/10.1161/JAHA.119.015291 .

Inoue A, Hifumi T, Sakamoto T, et al. Extracorporeal cardiopulmonary resuscitation in adult patients with out-of-hospital cardiac arrest: a retrospective large cohort multicenter study in Japan. Crit Care. 2022;26(1):1–11. https://doi.org/10.1186/s13054-022-03998-y .

Abrams D, MacLaren G, Lorusso R, et al. Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications. Intensive Care Med. 2022;48(1):1–15. https://doi.org/10.1007/s00134-021-06514-y .

Naito H, Sakuraya M, Hongo T, Takada H, Yumoto T, Yorifuji T. Prevalence , reasons , and timing of decisions to withhold / withdraw life-sustaining therapy for out - of - hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation. Crit Care . 2023:1–10. https://doi.org/10.1186/s13054-023-04534-2

Regarding the partial revision of the guidelines for the Organ Transplantation Law. https://www.mhlw.go.jp/hourei/doc/tsuchi/T231213H0020.pdf . Accessed on 19 Feb 2024.

Bougouin W, Dumas F, Lamhaut L, et al. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. Eur Heart J. 2020;41(21):1961–71. https://doi.org/10.1093/eurheartj/ehz753 .

Bougouin W, Cariou A, Jouven X. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: do not neglect potential for organ donation! Eur Heart J. 2020;41(37):3588. https://doi.org/10.1093/eurheartj/ehaa626

Aruga T. Revised organ transplant act and critical care physicians. Japan Med Assoc J. 2011;54(6):368–74.

Google Scholar  

Akabayashi A, Nakazawa E, Ozeki-Hayashi R, et al. Twenty years after enactment of the organ transplant law in Japan: Why are there still so few deceased donors? Transplant Proc. 2018;50(5):1209–19. https://doi.org/10.1016/j.transproceed.2018.02.078 .

Article   CAS   PubMed   Google Scholar  

Domínguez-Gil B, Ascher N, Capron AM, et al. Expanding controlled donation after the circulatory determination of death: statement from an international collaborative. Intensive Care Med. 2021;47(3):265–81. https://doi.org/10.1007/s00134-020-06341-7 .

Thuong M, Ruiz A, Evrard P, et al. New classification of donation after circulatory death donors definitions and terminology. Transpl Int. 2016;29(7):749–59. https://doi.org/10.1111/tri.12776 .

Escudero D, Valentín MO, Escalante JL, et al. Intensive care practices in brain death diagnosis and organ donation. Anaesthesia. 2015;70(10):1130–9. https://doi.org/10.1111/anae.13065 .

Seifi A, Lacci JV, Godoy DA. Incidence of brain death in the United States. Clin Neurol Neurosurg. 2020;195(January):105885. https://doi.org/10.1016/j.clineuro.2020.105885 .

Terunuma Y, Mathis BJ. Cultural sensitivity in brain death determination: a necessity in end-of-life decisions in Japan. BMC Med Ethics. 2021;22(1):1–6. https://doi.org/10.1186/s12910-021-00626-2 .

Oehler D, Böttger C, Immohr MB, et al. Reply to Thet et al. Comment on Oehler et al. Outcome and midterm survival after heart transplantation is independent from donor length of stay in the intensive care unit. Life 2022;12, 1053. Life. 2023;13(7). https://doi.org/10.3390/life13071444

Misar A, McLin VA, Calinescu AM, Wildhaber BE. Impact of length of donor ICU stay on outcome of patients after pediatric liver transplantation with whole and ex situ split liver grafts. Pediatr Transpl. 2022;26(2):1–11. https://doi.org/10.1111/petr.14186 .

Article   CAS   Google Scholar  

Bronchard R, Durand L, Legeai C, Cohen J, Guerrini P, Bastien O. Brain-dead donors on extracorporeal membrane oxygenation. Crit Care Med. 2017;45(10):1734–41. https://doi.org/10.1097/CCM.0000000000002564 .

Roumy A, Liaudet L, Rusca M, Marcucci C, Kirsch M. Pulmonary complications associated with veno-arterial extra-corporeal membrane oxygenation: a comprehensive review. Crit Care. 2020;24(1):1–10. https://doi.org/10.1186/s13054-020-02937-z .

Roth C, Schrutka L, Binder C, et al. Liver function predicts survival in patients undergoing extracorporeal membrane oxygenation following cardiovascular surgery. Crit Care. 2016;20(1):1–7. https://doi.org/10.1186/s13054-016-1242-4 .

Nakajima M, H Kaszynski R, Goto H, et al. Current trends and outcomes of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Japan: a nationwide observational study. Resusc Plus. 2020;4(October):100048. https://doi.org/10.1016/j.resplu.2020.100048

Chambers DC, Yusen RD, Cherikh WS, et al. The registry of the international society for heart and lung transplantation: thirty-fourth adult lung and heart-lung transplantation report—2017; focus theme: allograft ischemic time. J Heart Lung Transpl. 2017;36(10):1047–59. https://doi.org/10.1016/j.healun.2017.07.016 .

Kwong AJ, Ebel NH, Kim WR, et al. OPTN/SRTR 2021 annual data report: liver. Am J Transpl. 2023;23(2S1):S178–263. https://doi.org/10.1016/j.ajt.2023.02.006

Lentine KL, Smith JM, Miller JM, et al. OPTN/SRTR 2021 annual data report: kidney. Am J Transpl. 2023;23(2S1):S21–120. https://doi.org/10.1016/j.ajt.2023.02.004

Download references

Acknowledgements

We would like to thank the Japan Organ Transplant Network for providing data and supporting this project.

No funding was received for this work.

Author information

Authors and affiliations.

Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan

Tetsuya Yumoto, Kohei Tsukahara, Takafumi Obara, Takashi Hongo, Tsuyoshi Nojima, Hiromichi Naito & Atsunori Nakao

You can also search for this author in PubMed   Google Scholar

Contributions

TY, KT, TO, TH, TN, HN, and AN designed the concept of the study. TY retrieved the data and prepared the manuscript. KT, TO, TH, HN, TN, and AN made substantial revisions and edits. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Tetsuya Yumoto .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the Ethics Committee of the Japan Organ Transplant Network (Approved Number: 15) and the Ethics Committee of Okayama University Hospital (Approved Number: K2303-030). Informed consent from the patient's family or legal representative was waived in this study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1.

. The Kaplan–Meier curves comparing survival of unilateral (single) and bilateral (double) lung grafts among recipients from brain-dead organ donors, categorized by whether they received ECPR or not. The P values from the log-rank test for unilateral and bilateral lung graft survival were 0.049 and 0.104, respectively. The median observation periods for grafts from donors who experienced cardiac arrest and received ECPR versus those from non-ECPR donors, respectively, were as follows: for unilateral lung, 817 days (IQR: 553 to 1816) and 1311 days (IQR: 582 to 2196); and for bilateral lung, 707 days (IQR: 535 to 2174) and 1374 days (IQR: 695 to 2261). ECPR: extracorporeal cardiopulmonary resuscitation.

Additional file 2

. The Kaplan–Meier curves comparing survival of heart, lung, liver, pancreas, and kidney (both from donation after brain death and donation after circulatory death) grafts, according to two periods: 2010–2017 and 2018–2022. The left set of curves represents comparisons between ECPR and non-ECPR groups from 2010 to 2017. The middle set of curves shows comparisons between ECPR and non-ECPR groups from 2018 to 2022. The right set of curves compares the two time periods among patients who received ECPR. ECPR: extracorporeal cardiopulmonary resuscitation, DBD: donation after brain death, DCD: donation after circulatory death.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Yumoto, T., Tsukahara, K., Obara, T. et al. Organ donation after extracorporeal cardiopulmonary resuscitation: a nationwide retrospective cohort study. Crit Care 28 , 160 (2024). https://doi.org/10.1186/s13054-024-04949-5

Download citation

Received : 10 March 2024

Accepted : 10 May 2024

Published : 13 May 2024

DOI : https://doi.org/10.1186/s13054-024-04949-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Brain death
• Cardiopulmonary resuscitation
• Organ transplantation
• Tissue and organ procurement

Critical Care

ISSN: 1364-8535

• Submission enquiries: [email protected]

Donor information considered important to donors, recipients and offspring: an Australian perspective

Affiliation.

• 1 Concept Fertility Centre, PO Box 966, Subiaco 6904, Western Australia, Australia. [email protected]
• PMID: 21269882
• DOI: 10.1016/j.rbmo.2010.11.007

Donor conception research supports open-identity donor programmes and disclosure to donor-conceived offspring. This study examines Australian donors', recipients' and donor-conceived offspring's views on the importance of different types of biographical information about the donor. Participants (125 recipients, 39 donors (known, identity-release and anonymous), 23 donor-conceived offspring) completed an online or paper self-administered anonymous questionnaire. Individuals rated the importance of 15 types of biographical information and subsequently chose the three they deemed most important. All groups included donor's health history and name as key variables to be available to donor-conceived offspring. Recipients viewed the donor's decision to donate as important, donors thought their feelings about being contacted were important and donor-conceived offspring expressed an interest in the donor's own family. Sperm donors were less inclined to view the provision of information as important compared with offspring. For recipients, the importance of information became apparent once they had disclosed to their children. This is the first study to gauge Australian stakeholders' attitudes to release of information in the donor conception process. The findings support the move to open-identity donation systems and emphasize the importance of considering the varying perspectives of all stakeholders by policy developers.

Copyright © 2010 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

• Analysis of Variance
• Attitude to Health*
• Disclosure*
• Insemination, Artificial, Heterologous / psychology*
• Patient Access to Records / psychology*
• Surveys and Questionnaires
• Tissue Donors / statistics & numerical data*

• Technical Support
• Find My Rep

You are here

Preparing your manuscript.

What are you submitting? The main manuscript document The title page How do I format my article? Sage Author Services

What are you submitting? 

Sage journals publish a variety of different article types, from original research, review articles, to commentaries and opinion pieces. Please view your chosen journal’s submission guidelines for information on what article types are published and what the individual requirements are for each. Below are general guidelines for submitting an original research article. 

Whatever kind of article you are submitting, remember that the language you use is important. We are committed to promoting equity throughout our publishing program, and we believe that using language is a simple and powerful way to ensure the communities we serve feel welcomed, respected, safe, and able to fully engage with the publishing process and our published content. Inclusive language considerations are especially important when discussing topics like age, appearance, disability, ethnicity, gender, gender identity, race, religion, sexual orientation, socioeconomic status, emigration status, and weight. We have produced an Inclusive Language Guide that recommends preferred terminology on these topics. We recognize that language is constantly evolving and we’re committed to ensuring that this guide is continuously updated to reflect changing practices. The guide isn't exhaustive, but we hope it serves as a helpful starting point.  

The main manuscript document 

Have a look at your chosen journal’s submission guidelines for information on what sections should be included in your manuscript. Generally there will be an Abstract, Introduction, Methodology, Results, Discussion, Conclusion, Acknowledgments, Statements and Declarations section, and References. Be sure to remove any identifying information from the main manuscript if you are submitting to a journal that has a double-anonymized peer review policy and instead include this on a separate title page. See the Sage Journal Author Gateway for detailed guidance on making an anonymous submission .   

Your article title, keywords, and abstract all contribute to its position in search engine results, directly affecting the number of people who see your work. For details of what you can do to influence this, visit How to help readers find your article online .

Title: Your manuscript’s title should be concise, descriptive, unambiguous, accurate, and reflect the precise contents of the manuscript. A descriptive title that includes the topic of the manuscript makes an article more findable in the major indexing services.  

Abstract: Your abstract should concisely state the purpose of the research, major findings, and conclusions. If your research includes clinical trials, the trial registry name and URL, and registration number must be included at the end of the abstract. Submissions that do not meet this requirement will not be considered. Please see your chosen journal’s guidelines for information on how to set out your abstract.  

Keywords: You will be asked to list a certain number of keywords after the abstract. Keywords should be as specific as possible to the research topic.   

Acknowledgements: If you are including an Acknowledgements section, this will be published at the end of your article. The Acknowledgments section should include all contributors who do not meet the criteria for authorship. Per ICMJE recommendations , it is best practice to obtain consent from non-author contributors who you are acknowledging in your manuscript.   

Writing assistance and third-party submissions: if you have received any writing or editing assistance from a third-party, for example a specialist communications company, this must be clearly stated in the Acknowledgements section and in the covering letter. Please see the Sage Author Gateway for what information to include in your Acknowledgements section. If your submission is being made on your behalf by someone who is not listed as an author, for example the third-party who provided writing/editing assistance, you must state this in the Acknowledgements and also in your covering letter. Please note that the journal editor reserves the right to not consider submissions made by a third party rather than by the author/s themselves.   

Author contributions statement: As part of our commitment to ensuring an ethical, transparent and fair peer review and publication process, some journals have adopted CRediT (Contributor Roles Taxonomy) . CRediT is a high-level taxonomy, including 14 roles, which is used to describe each author’s individual contributions to the work. Other journals may require you to list the contribution of each author as part of the submission process. If so, please include an Author Contributions heading within your submission after the Acknowledgements section. The information you give on submission will then show under the Author Contributions heading later at the proofing stage.  

Statements and declarations: You’ll be asked to provide various statements and declarations regarding the research you’re submitting. These will vary by journal so do make sure you read your chosen journal’s guidelines carefully to see what is required. Please include a section with the heading ‘Statements and Declarations’ at the end of your submitted article, after the Acknowledgements section (and Author Contributions section if applicable) including the relevant sub-headings listed below. If a declaration is not applicable to your submission, you must still include the heading and state ‘Not applicable’ underneath. Please note that you may be asked to justify why a declaration was not applicable to your submission by the Editorial Office.

• Ethical considerations: Please include your ethics approval statements under this heading, even if you have already included ethics approval information in your methods section. If ethical approval was not required, you need to state this. You can find information on what to say in your ethical statements as well as example statements on our Publication ethics and research integrity policies page    
• Consent to participate: Please include any participant consent information under this heading and state whether informed consent to participate was written or verbal. If the requirement for informed consent to participate has been waived by the relevant Ethics Committee or Institutional Review Board (i.e. where it has been deemed that consent would be impossible or impracticable to obtain), please state this. If this is not applicable to your manuscript, please state ‘Not applicable’ in this section. More information and example statements can be found on our Publication ethics and research integrity policies page   
• Consent for publication: Submissions containing any data from an individual person (including individual details, images or videos) must include a statement confirming that informed consent for publication was provided by the participant(s) or a legally authorized representative. Non-essential identifying details should be omitted.  Please do not submit the participant’s actual written informed consent with your article, as this in itself breaches the patient’s confidentiality. The Journal requests that you confirm to us, in writing, that you have obtained written informed consent to publish but the written consent itself should be held by the authors/investigators themselves, for example in a patient’s hospital record. The confirmatory letter may be uploaded with your submission as a separate file in addition to the statement confirming that consent to publish was obtained within the manuscript text. If this is not applicable to your manuscript, please state ‘Not applicable’ in this section. If you need one you can download this template participant consent form . 
• Declaration of conflicting interest: All journals require a declaration of conflicting interests from all authors so that a statement can be included in your article. For guidance on conflict of interest statements, see our policy on conflicting interest declarations and the ICMJE recommendations . If no conflict exists, your statement should read: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
• Funding statement: All articles need to include a funding statement, under a separate heading, even if you did not receive funding .  You’ll find guidance and examples on our Funding statements page .  
• Data availability statement: We are committed to helping ensure you reach as many readers as possible, always in a spirit of openness and transparency. We encourage you to share your research to a public repository and cite this data in your research (please note that this is a requirement for some journals). You will need to publish a data availability statement with your article under this heading. More information on how to write one can be found on the Sage Gateway: Research Data Sharing FAQs | SAGE Publications Ltd   

Artwork, figures, and other graphics: Illustrations, pictures and graphs, should be supplied in the highest quality and in an electronic format that helps us to publish your article in the best way possible. Please follow the guidelines below to enable us to prepare your artwork for the printed issue as well as the online version. 

• Format: TIFF, JPEG: Common format for pictures (containing no text or graphs). 
• EPS: Preferred format for graphs and line art (retains quality when enlarging/zooming in). 
• Placement: Figures/charts and tables created in MS Word should be included in the main text rather than at the end of the document. 
• Figures and other files created outside Word (i.e. Excel, PowerPoint, JPG, TIFF and EPS) should be submitted separately. Please add a placeholder note in the running text (i.e. “[insert Figure 1.]") 
• Resolution: Rasterized based files (i.e. with .tiff or .jpeg extension) require a resolution of at least 300 dpi (dots per inch). Line art should be supplied with a minimum resolution of 800 dpi. 
• Colour: Please note that images supplied in colour will be published in colour online and black and white in print (unless otherwise arranged). Therefore, it is important that you supply images that are comprehensible in black and white as well (i.e. by using colour with a distinctive pattern or dotted lines). The captions should reflect this by not using words indicating colour. If you have requested colour reproduction in the print version, we will advise you of any costs on receipt of your accepted article. 
• Dimension: Check that the artworks supplied match or exceed the dimensions of the journal. Images cannot be scaled up after origination 
• Fonts: The lettering used in the artwork should not vary too much in size and type (usually sans serif font as a default). 

Please ensure that you have obtained any necessary permission from copyright holders for reproducing any illustrations, tables, figures, or lengthy quotations previously published elsewhere. For further information including guidance on fair dealing for criticism and review, please see the Frequently Asked Questions page on the Sage Journal Author Gateway.   

References: Every in-text citation must have a corresponding citation in the reference list and vice versa. Corresponding citations must have identical spelling and year. Information about what reference style to use can be found in your chosen journal’s guidelines. 

Authors should update any references to preprints when a peer reviewed version is made available, to cite the published research. Citations to preprints are otherwise discouraged.  

Supplemental material Sage journals can host additional materials online (e.g. datasets, podcasts, videos, images etc.) alongside the full text of the article. Your supplemental material must be one of our accepted file types. For that list and more information please refer to our guidelines on submitting supplemental files .  

The title page  

You will also need to prepare a title page. This should include any information removed from the main manuscript document for the purposes of anonymity. The title page will not be sent to peer reviewers.  

Your title page should include:  

• Article title  
• The full list of authors including all names and affiliations. 
• The listed affiliation should be the institution where the research was conducted. If an author has moved to a new institution since completing the research, the new affiliation can be included in a note at the end of the manuscript – please indicate this on the title page.  
• Everybody eligible for authorship must be included at the time of submission (please see the authorship section for more information).
• Contact information for the corresponding author: name, institutional address, phone, email  
• Acknowledgments section  
• Statements and Declarations section  
• Any other identifying information related to the authors and/or their institutions, funders, approval committees, etc, that might compromise anonymity.   

How do I format my article? 

The preferred format is Word. There is no need to follow a specific template when submitting your manuscript in Word. However, please ensure your heading levels are clear, and the sections clearly defined. 

(La)TeX guidelines We welcome submissions of LaTeX files. Please download the  Sage LaTex Template , which contains comprehensive guidelines. The Sage LaTex template files are also available in  Overleaf , should you wish to write in an online environment. 

If you have used any .bib or .bst files when creating your article, please include these with your submission so that we can generate the reference list and citations in the journal-specific style. If you have any queries, please consult our  LaTex Frequently Asked Questions.  

When formatting your references, please ensure you check the reference style followed by your chosen journal. Here are quick links to the  Sage Harvard  reference style, the  Sage Vancouver  reference style and the  APA  reference style. 

Other styles available for certain journals are:  ACS Style Guide ,  AMA Manual of Style ,  ASA Style Guide ,  Chicago Manual of Style  and  CSE Manual for Authors, Editors, and Societies . 

Please refer to  your journal's manuscript submission guidelines  to confirm which reference style it conforms to and for other specific requirements. 

Equations should to be submitted using Office Math ML and Math type. 

Artwork guidelines   Illustrations, pictures and graphs, should be supplied in the highest quality and in an electronic format that helps us to publish your article in the best way possible. Please follow the guidelines below to enable us to prepare your artwork for the printed issue as well as the online version. 

• Format:  TIFF, JPEG: Common format for pictures (containing no text or graphs).  EPS: Preferred format for graphs and line art (retains quality when enlarging/zooming in). 
• Placement:  Figures/charts and tables created in MS Word should be included in the main text rather than at the end of the document.  Figures and other files created outside Word (i.e. Excel, PowerPoint, JPG, TIFF and EPS) should be submitted separately. Please add a placeholder note in the running text (i.e. “[insert Figure 1.]") 
• Resolution:  Rasterized based files (i.e. with .tiff or .jpeg extension) require a resolution of at least  300 dpi  (dots per inch). Line art should be supplied with a minimum resolution of  800 dpi . 
• Color:  Please note that images supplied in colour will be published in color online and black and white in print (unless otherwise arranged). Therefore, it is important that you supply images that are comprehensible in black and white as well (i.e. by using color with a distinctive pattern or dotted lines). The captions should reflect this by not using words indicating colour. 
• Dimension:  Check that the artworks supplied match or exceed the dimensions of the journal. Images cannot be scaled up after origination 
• Fonts:  The lettering used in the artwork should not vary too much in size and type (usually sans serif font as a default). 

Image integrity Figures should be minimally processed and should reflect the integrity of the original data in the image. Adjustments to images in brightness, contrast, or color balance should be applied equally to the entire image, provided they do not distort any data in the figure, including the background. Selective adjustments and touch-up tools used on portions of a figure are not appropriate. Images should not be layered or combined into a single image unless it is stated that the figure is a product of time-averaged data. All adjustments to image date should be clearly disclosed in the figure legend. Images may be additionally screened to confirm faithfulness to the original data. Authors should be able to supply raw image data upon request. Authors should also list tools and software used to collect image data and should document settings and manipulations in the Methods section. 

Sage Author Services 

Authors seeking assistance with English language editing, translation with editing, or figure and manuscript formatting, to fit the journal’s specifications should consider using Sage Author Services. Other additional services include creation of infographics and video summaries to promote your article with colleagues and over social media. Visit  Sage Author Services  on our Journal Author Gateway for further information. 

• Open access at Sage
• Top reasons to publish with Sage
• How to get published
• Open access and publishing fees
• Sage Author Services
• Help readers find your article
• Plain Language Summaries
• Inclusive language guide
• Registered reports author guidelines
• Publication ethics policies
• Supplemental material author guidelines
• Manuscript preparation for double-anonymized journals
• Advance: a Sage preprints community
• Submitting your manuscript
• During peer review
• During and post publication
• Sage editorial policies
• Help and support
• Journal Editor Gateway
• Journal Reviewer Gateway
• Ethics & Responsibility
• Publication Ethics Policies
• Sage Chinese Author Gateway 中国作者资源

The Importance of Donors and Donor Research

Collaborative approaches to donor research, donor research in australia, challenges to collaborative research, research focus - initiating and maintaining plasma donation, research focus - pride and donation motivation, conclusions, acknowledgements, disclosure statement, donor research in australia: challenges and promise.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• Open the PDF for in another window
• Get Permissions
• Cite Icon Cite
• Search Site

Barbara Masser , Geoff Smith , Lisa A. Williams; Donor Research in Australia: Challenges and Promise. Transfus Med Hemother 1 July 2014; 41 (4): 296–301. https://doi.org/10.1159/000365016

Download citation file:

• Ris (Zotero)
• Reference Manager

Donors are the key to the core business of Blood Collection Agencies (BCAs). However, historically, they have not been a focus of research undertaken by these organizations. This model is now changing, with significant donor research groups established in a number of countries, including Australia. Donor research in the Australian Red Cross Blood Service (Blood Service) is concentrated in the Donor and Community Research (DCR) team. Cognizant of the complex and ever-changing landscape with regard to optimal donor management, the DCR team collaborates with academics located at universities around Australia to coordinate a broad program of research that addresses both short- and-long term challenges to the blood supply. This type of collaboration is not, however, without challenges. Two major collaborative programs of the Blood Service's research, focusing on i) the recruitment and retention of plasmapheresis donors and ii) the role of the emotion pride in donor motivation and return, are showcased to elucidate how the challenges of conducting collaborative BCA research can be met. In so doing, these and the other research programs described herein demonstrate how the Blood Service supports and contributes to research that not only revises operational procedures but also contributes to advances in basic science.

Donors are the key to the core business of blood collection agencies (BCAs). Despite significant advances in the science of blood substitutes [ 1 ], it remains the case that without donors there is no blood to be collected and no need for BCAs. Yet, donors have been comparatively neglected in transfusion medicine research [ 2 ]. With a few notable exceptions [ 3,4 ], the period up to the year 2000 saw transfusion medicine make substantial advances in the application of blood products, yet there was little evidence of a move towards a sophisticated understanding of the motivations of individuals to provide those products on which transfusion medicine depends. That is, the primary focus of BCAs and researchers was not on what motivates individuals to become, and remain, blood donors. This led Stephen and collegues [ 5 ], in a review of the Australian blood banking and plasma product sector, to state: ‘although there is a considerable body of literature on donor motivation, much of it is of poor quality' (p. 68).

In the decade or so since that report, there has been a substantial increase in the volume of high-quality research undertaken on donor recruitment and retention. While descriptive survey research dominates [ 6 ], experiments [ 7,8 ] and randomized controlled trials [ 9,10 ] are also being conducted to determine effective ways to recruit and retain donors. This refocus on donors comes at a time when research questions are increasingly complex. In Australia, and is the case worldwide, there is a shift in demand away from whole blood towards plasma [ 11,12 ]. Specifically, in Australia, the forecasted decline in red blood cells (of 3% in 2013/2014, 2% in 2015/2016 before plateauing in 2016/2017) is contrasted with a 5% annual increase in plasma targets and a predicted constant demand for platelets through 2016/2017. This means that the recruitment and retention of donors to a single panel is no longer an optimal strategy for many BCAs [ 13 ]. Rather, BCAs now need to manage their donors to supply various blood products as demanded [ 14 ]. As such, the research agenda in donor research is broadening.

In response to this, many BCAs now actively invest in donor research. Successful donor research collaborations between BCAs and researchers take a variety of formats. One method is for BCAs to establish an internal donor research division. Sanquin, a BCA in the Netherlands, adopts this approach with their research division employing 120 researchers [ 15 ]. Within this division, the Donor Studies section employs social and behavioral scientists to investigate donor recruitment, retention and management [ 15 ]. This integrated model has resulted in high-quality research, characterized by high participation rates. Research from the Donor Studies section has, amongst other achievements, quantified retention rates following first-time donor adverse events, predicted deferral rates due to low hemoglobin, explored the impact of educational level and other cultural factors on blood donation behavior, and identified predictors of plasma panel membership [ 16,17,18,19 ].

BCAs in the USA and Canada take a different approach. Some BCAs have formed productive collaborations with university research laboratories and institutes. For example, Professor Christopher France's laboratory, located at Ohio University, conducts research with the operational support of the Community Blood Service of Greater Kansas City [ 20 ] and the American Red Cross [ 20,21 ]. These BCA-university collaborations have advanced our understanding of how recruitment information can be tailored to optimize donor recruitment through modified recruitment brochures and interactive online donor preparation materials [ 21,22 ].

In Canada, Professor Gaston Godin of Laval University has collaborated extensively with Hema-Quebec, a BCA independently serving Quebec province's blood product needs [ 6,9,23 ]. Further, and in conjunction with the Social Sciences and Humanities Research Council of Canada, Hema-Quebec co-funds a Research Chair on the Social Aspects of Blood Donation at the National Institute of Scientific Research (INSR). Professor Johanne Charbonneau currently holds this chair. This co-funding arrangement has enabled substantial advances in our understanding of the influence of family on donation decisions and explored motivators and barriers to recruiting donors from ethnic minority groups [ 24,25,26 ]. These dynamic collaborations between BCAs and university researchers in Europe and North America have resulted in substantial, important contributions to our basic scientific understanding of donor characteristics, motivations, and behaviors.

In Australia, the Australian Red Cross Blood Service (hereafter, the Blood Service) has an internal donor research group that collaborates extensively with university-based researchers across Australia. These collaborations began in response to the review of the extant knowledge about donors and donor behavior by Stephen et al. [ 5 ]. The review highlighted ‘a need for strategic research partnerships between the ARCBS and academic units' (p. 69) [ 5 ]. The Blood Service responded by investing in the foundations of the Donor and Community Research (DCR) team located within the Research and Development division of the Blood Service. As of early 2014, the DCR team comprises two postdoctoral research fellows and five research assistants led by a Program Leader. The group conducts high-quality research that results both in academic output and revisions to standard operating procedures within the Blood Service with the ultimate aim of ensuring a sustainable and safe supply of blood products within Australia.

A diffuse ‘hub and spoke' model characterizes the Blood Service's collaborative research. The Blood Service serves as the ‘hub,' with ‘spokes' reaching out to many Australian universities. This model allows the Blood Service to benefit from the expertise of researchers at the forefront of relevant disciplines such as psychology, education, marketing, economics, statistics and public health. This model also gives the Blood Service the opportunity to lever additional funding from the Australian Government, through the Australian Research Council's Linkage Project grant scheme (which involves financial contributions both from an industry partner and the government) as well as through university-based funding schemes.

The DCR investigates two broad areas - first, understanding donors in the context of their (potential) interaction with the Blood Service, and second, supporting donor recruitment, retention, and reactivation. Some of the projects in these topics are detailed below.

One key focus of the research centered on understanding donors' interactions with the Blood Service has been on understanding how (potential) donors from emerging cultural minority groups interact with the Blood Service. While donation rates from established migrant groups (e.g., those from Europe and Asia) are broadly satisfactory, the donation rate of members of emerging migrant groups (e.g., Africa) has been identified as less than optimal [ 27 ]. Working alongside the DCR team and funded jointly by the Blood Service and the Australian Research Council, researchers at Deakin and Monash Universities are developing and evaluating a culturally adaptable social marketing intervention to increase blood donation rates among African migrant communities. This research builds on prior work on inhibitors and motivators of blood donation within this group [ 27,28,29 ]. This research will contribute to a sustainable blood supply in terms of rare blood types found in individuals from these communities [ 30 ].

Collectively, donor recruitment, retention, and reactivation comprise the second key area of research for the DCR team. To maintain a cost-effective sustainable blood supply, it is critical for BCAs to maximize donor retention [ 31,32 ] and reactivate those who lapse. Within this area, the DCR team collaborates with university researchers to examine affective influences on donor retention [ 7 ], the initiation and maintenance of plasma donation [ 33,34,35 ], the role of social media in donor retention, and the effectiveness of a critical blood donation registry.

Research within these topics comprises programs that address the different needs of those involved in the collaboration. However, conducting research with donors remains a challenge. BCAs have traditionally focused on manufacturing and, as such, many established internal processes and systems are ill-suited to conducting social and behavioral research.

Challenge 1: Balancing the Tension between Operational Outcomes and Contribution to Science

The historical focus of BCAs on manufacturing highlights a fundamental tension for applied researchers - that is, how to conduct scientifically rigorous research that contributes to basic knowledge in a timeframe that allows the outcomes to be relevant to the ever-changing operational demands of industry partners such as BCAs. Within this context, academic researchers must demonstrate how basic scientific findings can be applied to the day-to-day operations of a BCA. Further, programs of collaborative research need to be structured in such a way as to allow incremental outcomes that can be disseminated both internally at the BCA to inform operations and externally via academic journals and other professional outlets.

Challenge 2: Adaptability of Research Questions to Current BCA Needs

The landscape of blood donation research is constantly shifting - thus collaborative research needs to be able to adapt when the need arises. One aspect of this challenge is the rapidity with which research answers can be obtained. Often, BCAs require donor research that can provide a ‘quick' answer to a particular operational question. While research to address such questions has traditionally fallen within the remit of marketing and ‘test and learn' procedures [ 36 ], this kind of research question can also be answered effectively by research and development teams.

Challenge 3: Conducting Research within the Complex Research Environment of Donor Behavior

Challenges in conducting research with blood donors also occur in relation to the form and methodology of the research, particularly in the domain of participant recruitment. A balance must be reached between protecting donors from burdensome contact (which may drive them away from the BCA) and the desire to recruit them into research. In the Australian context, donors are protected from excess contact by a donor contact process that requires checks of the eligibility of donors for recruitment prior to approaching them to participate. Further, research on ‘in-center experience' (as with the research on donor pride detailed below) raises practical challenges with regard to collecting data from donors in often space- and time-constrained donor centers.

Another challenge is the handling of donor data. As recent research suggests question-behavior effects in donor research [ 6,9,31 ], it is important not only to model measured constructs amongst the recruited donor sample but also to compare behavior of the recruited sample to a matched donor sample who did not participate in the research. Fortunately, collaboration with a BCA enables this type of comparison, as BCAs maintain detailed donor records. Finally, challenges arise with regard to the ‘duty of care' of donor behavior researchers. This is best illustrated with regard to reporting of adverse events (AEs) [ 37 ]. BCAs have a strong and appropriate desire to track and record donor AEs, not only for protective care reasons but also because AEs predict donor return [ 38,39 ]. Because of this, collaborative research teams who assess donors' self-reports of AEs (e.g., via the BDRI) [ 40 ] must decide upon procedures and practices that ensure proper back-reporting to donor care teams.

Two recent projects arising out of collaborations of the Blood Service with the University of Queensland, exploring plasma donation, and the University of New South Wales, exploring pride as motivation for whole blood donation, demonstrate how these challenges can be met. In describing these projects, we highlight how we have handled such challenges in both a creative and dynamic manner.

While much has been written in the transfusion medicine journals on plasma and platelet apheresis, the typical focus has been on the physiological effects of donating [ 41,42 ]. For BCAs operating in voluntary, non-remunerated contexts, there is no established literature on what motivates donors to become and remain plasma and/or platelet donors. In contexts such as these, behavior and decision-making theories are critical tools [ 43 ]. Adopting and augmenting the current dominant theoretical framework in blood donor research (the Theory of Planned Behavior; [ 44 ]), Barbara Masser at the University of Queensland and colleagues have undertaken a systematic program of research in collaboration with the Blood Service to understand the psychological antecedents of successful conversion of donors from whole blood to plasma donation. This research is co-funded by the Blood Service and the Australian Research Council, and employs a full-time research fellow located at the National Office of the Blood Service. The location of the research fellow in the National Office allows for full integration of the research within standard Blood Service operation as well as allowing for the fast dissemination of key findings - challenge 1 .

The aim of this research program is to understand plasma donation from the donor's perspective [ 33,34,35,47 ] and to identify factors that predict whether whole blood donors become plasmapheresis donors [ 34,45 ]. Current research within this program is focused on identifying factors that promote flexible donor loyalty - that is retention in the context of being willing to move between panels [ 47 ]. This re-orientation away from the originally planned focus on plasma panel retention is in direct response to an emerging need to balance short- and long-term demand and supply [ 14 ] - challenge 2 . In line with the recommendations of [ 8 ], an intervention to promote flexible loyalty will be developed and evaluated in a field experiment.

This program of research has already yielded insight into donors' perspectives on plasmapheresis and has contributed to revised operating procedures. Bove et al. [ 36 ] determined that the key trigger to conversion to plasmapheresis was a personal request to convert. As a result of this, standard Blood Service plasmapheresis conversion practices now frequently include personal approaches to donors - challenge 1 . Bagot et al. [ 30 ] identified key deterrents to conversion and provided preliminary strategies for agencies to recruit and retain to the plasmapheresis panel. These recruitment strategies were further clarified by Bagot et al. [ 47 ] who identified that the key ingredients to successful ‘conversion conversations' are that they occur early in the donor's whole blood career, are donor-centric, and are, whenever possible, donor-initiated.

In line with the aim of contributing to both basic science and operational practice, Masser et al. [ 45 ] suggested a more complicated role of donor (role) identity in plasmapheresis donation than previously assumed. The development of a donor identity has frequently been promoted as the ultimate end goal [ 3,48 ]. Those who view their role as a donor as an important part of their self are inherently motivated to keep donating. However, Masser et al. [ 45 ] found donor role identity to be a significant negative predictor of intention to convert. Masser et al. [ 45 ] suggested that, for current whole blood donors, plasmapheresis was a behavior incongruent with their whole blood donor role identity, and recommended that BCAs encourage donors, through the use of strategic agency cues, to extend their sense of personal responsibility to encompass all forms of donation - challenge 1.

While descriptive research using survey methodology is important in contexts where knowledge is under-developed, such as plasmapheresis, there is also a pressing need to show causal relationships. To this end, experiments are invaluable. However, experiments are difficult to conduct in applied settings, particularly in field settings that are heavily regulated such as donor centers, and can be costly in terms of participant hours - challenge 3 . The DCR team at the Blood Service actively supports research involving tightly controlled laboratory studies augmented with field research, as in this project on plasma donation. Further, this type of collaboration with the Blood Service allows for the access to objective data on subsequent donation behavior, eliminating problems associated with self-report data - challenge 3.

Most research on the psychological antecedents to donation has focused on donors' cognitions about donating. Recently, research has begun to explore the role of emotion in blood donation decision-making. For example, fear, anxiety, and regret all impact donor intention and behavior (see [ 49,50 ] for recent meta-analyses). In line with this trend, Lisa Williams at the University of New South Wales commenced a project with the Blood Service in 2012 investigating the role of pride in motivating and maintaining blood donation.

Pride stands as a strong candidate for a source of blood donation motivation. Pride arises from situations of success across a wide range of domains (e.g., academic, career, and athletic). Most relevant to blood donation, pride also arises from performance of moral behaviors. Feelings of pride motivate future goal-directed behaviors aimed at achieving future success and/or having success recognized by others [ 51,52 ]. Further, just as anticipating a joyful outcome can elicit anticipatory happiness [ 53 ] , contemplating a future success can elicit anticipated pride.

Combining a longitudinal study of donors recruited in-center with a laboratory-based experimental study of anticipated pride, a new program was developed to cultivate an empirical understanding about the role of pride in motivating blood donation. This program of research had the concurrent aim to inform the Blood Service's future donor communication strategies - challenge 1.

Recruiting participants for longitudinal research present operational challenges for researchers and BCAs. For the longitudinal study in this project, donors were recruited in the refreshment area center post donation. Donors were asked to complete a survey immediately and three follow-up surveys online. Recruitment for this project was challenging as donors had to be recruited whilst avoiding impacting normal operations, and had to be willing to participate in multiple surveys investing significant amounts of their time - challenge 3 . Another component of challenge 3 arose in this phase: reviewing and back-reporting of severe AEs. Even though these instances were extremely rare, and were corroborated by Blood Service staff at the time of donation, duty of care required that the research staff consistently reviewed participants' responses to the BDRI [ 40 ] and took appropriate action when needed.

The trajectory of a longitudinal study such as this is quite lengthy. Recruitment is time-intensive; it took 9 months to recruit 300 donors who completed all four surveys. The full dataset for each participant was finalized 6 months after the final survey date, in order to include objective behavioral data showing if, and when, donors returned to donate again. To facilitate outcomes for the Blood Service, data coding and analysis was done concurrently with data collection, thus allowing the project team to extract findings of key interest to the Blood Service as they became available - challenge 1 . Approaches like this allow the Blood Service to implement operational changes on the basis of research findings as soon as possible.

The trajectory of the laboratory study also speaks to accommodating the changing operational needs of a collaborating BCA - challenge 2 . At the commencement of this stage of the project, there was substantial interest from the Blood Service in identifying emotional responses to blood donation imagery and how those emotions subsequently affect donation intention. In response, the original experimental design was modified in three ways: i) a within-subjects design was adopted in order to account for person-specific variability in responses, ii) the experimental task was changed, so participants viewed images that varied along operationally relevant dimensions, and iii) future intentions to donate were measured. While the focus remained on pride, the scope of the project was increased to meet the current operational demands of the Blood Service. The project team then confirmed support from other divisions within the Blood Service (e.g., marketing), to facilitate design and launch of the laboratory study.

Across both the longitudinal and laboratory studies, flexibility and close collaboration have been the key to the success of this project. Further, support from a variety of divisions within the Blood Service, beyond the DCR team, has been an integral part to the project's success. For example, the longitudinal study would not have been possible without support from donor center managers and staff. As such, this project represents a vibrant collaboration that will produce rigorous findings relevant to the scientific community as well as providing operational tools for BCAs.

Reflecting international trends, donor research is now part of the core business of the Blood Service in Australia. Through strategic collaborations, the DCR team is able to facilitate a broad research program that addresses needs across the organization. Further, through a diffuse ‘hub and spoke' model, the Blood Service levers significant academic contributions while minimizing internal costs. There are many challenges to conducting donor research in BCAs including i) balancing the tension between operational outcomes and contribution to basic science, ii) the need for research questions to be quickly adapted to ever-changing BCA needs, and iii) practical challenges emerging from attempts to conduct social and behavioral research with donors. As evidenced by the program of research on plasma donation led by Masser and the program of research on the motivational effects of pride led by Williams, these challenges can, however, be met. This allows researchers both within the Blood Service and external to it to contribute to advances in basic science and to operation. Cognizant of the different needs of the Blood Service, the DCR team and collaborators pursue research that allows an empirically based contribution to discussions and changes to procedure in response to both short- and long-term challenges to the blood supply.

This research was supported by the Australian Research Council (LP100100408) and the Australian Red Cross Blood Services (the Blood Service). We would like to acknowledge the Australian governments that fully fund the Blood Service for the provision of blood products and services to the Australian community.

In producing this article the authors certify that they have no conflict of interest beyond the research funding and employment (Dr. G. Smith) declared.

Email alerts

Citing articles via, suggested reading.

• Online ISSN 1660-3818
• Print ISSN 1660-3796

INFORMATION

• Contact & Support
• Information & Downloads
• Rights & Permissions
• Terms & Conditions
• Catalogue & Pricing
• Policies & Information
• People & Organization
• Stay Up-to-Date
• Regional Offices
• Community Voice

SERVICES FOR

• Researchers
• Healthcare Professionals
• Patients & Supporters
• Health Sciences Industry
• Medical Societies
• Agents & Booksellers

Karger International

• S. Karger AG
• P.O Box, CH-4009 Basel (Switzerland)
• Allschwilerstrasse 10, CH-4055 Basel
• Tel: +41 61 306 11 11
• Fax: +41 61 306 12 34
• Contact: Front Office
• Experience Blog
• Privacy Policy
• Terms of Use

This Feature Is Available To Subscribers Only

Sign In or Create an Account

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.15(10); 2023 Oct
• PMC10638672

A Review of Amelioration of Awareness About Blood Donation Through Various Effective and Practical Strategies

Akshay dorle.

1 Pathology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research, Nagpur, IND

Ujwal Gajbe

2 Anatomy, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research, Nagpur, IND

Brij Raj Singh

Obaid noman, pratibha dawande.

Blood donations play a crucial role in medical care; however, the global shortage of donors remains and has a serious impact on medical interventions. The challenges involved include the lack of public awareness of the importance of blood donation, the lack of understanding of the process and eligibility criteria for blood donation, and the lack of comprehensive strategies aimed at raising awareness and participation among potential donors, with particular emphasis on the involvement of young people. It is essential to recognize that blood donation delivers significant benefits to donors and recipients, improves overall health, and ultimately saves lives. Various initiatives, such as blood donation camps, dynamic social media campaigns, and strategic networking of medical professionals, have proved effective in promoting blood donation. In particular, in the event of an emergency, the availability of sufficient blood supplies is increasingly essential, underlining the urgent need to establish and maintain a sustainable blood donor network. An in-depth understanding of the motivation and conservation of donors is crucial in this context, as it is known that demographic factors significantly impact the frequency of blood donation. In addition, ethical and legal considerations require careful attention, highlighting the essential role of obtaining informed consent and ensuring the confidentiality of donors throughout the process. As we look ahead to the evolving landscape, it presents a series of formidable challenges. These challenges encompass the critical necessity to broaden and diversify our donor base, thereby extending and varying our sources of financial support for specific initiatives, organizations, or projects. Moreover, we must proactively harness the opportunities presented by emerging technologies and commit ourselves to closing the information gaps within the existing public knowledge sphere. In summary, the review emphasizes the paramount importance of ongoing efforts to strengthen and enrich donors' engagement through customized strategies and educational outreach.

Introduction and background

Blood donation is a crucial component of healthcare that saves thousands of lives annually [ 1 ]. The global shortage of donors is an essential issue, driven primarily by low blood donation rates. It has significant implications for healthcare systems worldwide, as safe and adequate blood supplies are critical to the success of various medical interventions. It can help us preserve life and improve our society's general condition [ 2 ]. Transfusion of blood is an essential medical procedure. Various organizations, including healthcare organizations, blood banks, and non-profit organizations dedicated to blood donation and transfusion services, are formulating numerous strategies to tackle the issue, which include initiatives aimed at raising awareness and motivating individuals to contribute to blood donation [ 3 ]. However, despite its importance, the general population must still understand and realize the benefits. Of the 171 countries surveyed by the WHO, 62 have a 100% voluntary unpaid system for blood donation. In an unforced and overdue system, donors and recipients are unspecified [ 4 ]. The younger generation represents the most promising source for ensuring a secure and sustainable blood supply in the future [ 5 ]. While the process is expeditious and commonly practiced in various medical operations, there is a global shortage of blood donors. According to the WHO, a nation can only provide sufficient blood for patients requiring transfusions through a system based on voluntary, unpaid blood donations. The world has a shortage of blood donors [ 6 - 8 ]. According to the American Red Cross, someone in the United States requires blood every two seconds, and transfusions of blood and blood components have saved thousands of lives [ 1 , 8 ]. The current review assesses the most recent strategies implemented to increase awareness and encourage greater participation among blood donors [ 9 ]. It also determines whether young people know and have attitudes toward voluntary blood donation. Understanding these strategies will allow us to identify best practices and enhance our efforts to convince more people to donate blood, thus saving more lives. This review article aims to explore utilizing the most recent strategies, thereby enhancing awareness by applying cutting-edge approaches.

The findings have been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) principles and criteria.

Search Sources/Search Strategy

The literature search was conducted through a review of electronic databases like PubMed, Google Scholar, and Scopus using appropriate keywords such as "Blood donation," "Raising awareness," "Latest strategies in blood donation," "blood donation," "blood transfusion," "blood component," "awareness campaign on blood donation," "challenges in blood donation," "future challenges in blood donation," and "transfusion." We obtained the most pertinent research papers and used them in different arrangements using the boolean operators "AND" and "OR" [ 10 ].

Inclusion and Exclusion Criteria

We focused on papers written in the English language relevant to the central questions of this review article, and that are narrative reviews such as randomized clinical trials and observational studies. We, however, excluded papers published in languages other than English, irrelevant to the questions, and related to topics.

Number of Articles Included in the Final Review

In the following PRISMA chart, the results show that out of the 1031 records identified, 15 were utilized for studies (Figure ​ (Figure1 1 ).

n = number of studies; PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analysis.

The review included seven articles that discussed using social media and software. Additionally, four articles examined how community-based events can increase blood donation and foster partnerships with various organizations. Furthermore, three articles emphasized regular participation and promotion by actors and players (Table ​ (Table1 1 ).

As per the study referenced, it is evident that the predominant utilization of software and social media applications has led to a notable increase in blood donation rates [ 11 - 15 , 19 , 20 ]. Furthermore, successfully implementing blood donation and promotion strategies involves hosting community events, forging partnerships with business organizations, and emphasizing regular engagement [ 16 - 18 , 21 ]. The involvement of influential public figures, or star personalities, also plays a pivotal role in these efforts [ 22 - 24 ]. This review article provides a comprehensive description of the implications of the latest strategies as detailed in the included articles within Table ​ Table2 2 and Figure ​ Figure2 2 .

Importance of blood donation and its impact on healthcare

Blood donation is an essential aspect of healthcare. It has been used in various medical procedures such as complications during childbirth, cancer treatment, burns, surgeries, accidents, and genetic blood disorders [ 28 , 29 ]. Several studies have designated that most of the blood, when donated by adults, is transfused to elderly patients in need [ 30 - 34 ]. Excessive use of blood at present could result in a shortage in the future, as numerous medical procedures such as surgery, trauma, and cancer treatments often necessitate significant quantities of blood. Therefore, everyone must recognize the importance of blood donation [ 27 ]. Donating blood and utilizing blood banking by public and non-profit organizations, along with securing low-cost supplies, could assist with blood donation during emergencies [ 35 , 36 ].

History of blood donation

The first successful blood transfusion between dogs occurred in the 17th century, beginning the history of blood donation. However, the use of human blood transfusions did not increase significantly until the early 1900s [ 37 ]. The ABO blood types were identified in 1901 by Austrian pathologist Karl Landsteiner, a development in the transfusion medicine sector. With the help of this discovery, it became feasible to match donors and recipients more precisely, lowering the chance of transfusion responses. The first blood bank opened in New York City in 1914 [ 38 ]. This made blood more readily available to patients who needed it by facilitating its storage and transportation. The need for blood transfusions skyrocketed during World War I. This resulted in the creation of blood donor programs and mobile blood drives. The Rhesus (Rh) blood factor was identified in the 1940s [ 39 ]. The danger of transfusion responses was further decreased because of this significant advancement in transfusion medicine [ 40 ].

Blood donation eligibility requirements

The donor should fall within the age group of 18-65 years and must weigh a minimum of 45 kilograms. Blood donation relies on assessing crucial parameters, including the donor's age, weight, temperature, blood pressure, and pulse. Furthermore, to guarantee the safety and eligibility of the donation, an evaluation of the donor's overall health, sexual orientation, and travel history is also conducted [ 41 ]. Other factors influencing blood donation practice include gender, age, religion, knowledge, attitude, level of schooling, self-perceived health status, and family education are all factors to consider [ 9 ]. Blood donation is a carefully controlled practice that guarantees the safety and effectiveness of collected blood and its components, whether used as essential components of contemporary transfusion medicine, as a therapeutic approach, or as supplementary care to other clinical therapies [ 42 ]. Antibody testing is a diagnostic approach used to detect HIV infections, and its implementation can effectively reduce the risk of disease transmission [ 43 ]. In India, the practice of transfusion-transmitted infection testing encompasses screening for five distinct diseases, namely HIV-I and HIV-II, hepatitis B virus (HBV), hepatitis C virus (HCV), Malaria, and Syphilis [ 30 , 44 ]. The eligibility criteria for blood donation among lesbian, gay, bisexual, and transgender (LGBTQ) individuals exhibit variation across different countries. In several nations, LGBTQ individuals may be eligible to donate blood provided they have not engaged in sexual activity with a new partner in the preceding three months [ 45 ]. Healthcare professionals should obtain the appropriate consent from the donor and recipient before blood donation [ 46 ].

Figure ​ Figure3 3 shows the steps involved in the blood donation process [ 40 - 46 ]. Once donors register for the blood drive, their blood is carefully collected, following stringent protocols to maintain donor safety. Subsequently, the collected blood undergoes thorough screening processes before it is dispatched in sealed blood bags to ensure its suitability for transfusion [ 40 , 41 ]. Blood bags are transported within specialized blood bag boxes designed to uphold the crucial temperature conditions required for preserving the integrity of the blood products during transit. This temperature control ensures that the blood remains safe and effective for medical use [ 41 , 42 ]. To maintain blood product safety, transferring the blood to a container with a temperature of less than +10 °C, such as a cold box or an insulated carrier, is essential. This controlled temperature environment helps preserve the quality and effectiveness of the blood during transportation to medical facilities for patient care [ 43 , 44 ]. Blood is effectively utilized through a well-organized system of distribution and its subsequent usage in medical procedures. This critical process ensures that donated blood reaches those in need, saving lives in healthcare settings worldwide [ 45 , 46 ].

°C: Degree Celsius.

Figure composed based on [ 40 - 46 ].

Awareness campaigns and initiatives

Blood donation awareness campaigns are vital for educating people about the importance of donating blood and ensuring a steady supply. These campaigns involve creating impactful visuals and leveraging social media for broad outreach [ 47 ]. Different initiatives, such as blood donation camps, can increase blood donation [ 48 ]. Repeated donors can educate young people about the need to be regular blood donors, and the mental influence they can create can increase the rate of youth blood donation [ 25 ]. One of the projects involves utilizing various social media channels to disseminate information about blood donation, highlighting the benefits it provides to both the donor and recipients [ 12 ]. Social media has emerged as the preferred source for sending and receiving information about blood donation. Utilizing social media platforms can improve blood donation practices when there is a donor shortage [ 12 ]. Organizing donation drives in convenient locations, partnering with influencers, and conducting educational workshops help dispel myths and motivate donors [ 48 ].

Donor motivation and retention

Donor motivation and retention are essential for a stable blood supply. Sex, age, and other donor information demographic considerations influence the possibility of future donations [ 49 ]. There is variation in the level of satisfaction among blood donors according to subgroups of demographics and contribution history. In addition, satisfaction positively correlates with the motivation to return for future donations. While generosity remains the primary motivating factor for all donors, optimizing future donation campaigns to cater to specific demographic subgroups might be crucial to enhancing motivation for future contributions [ 50 ]. There is a need to educate youth about the importance of becoming regular blood donors and the significant impact they can have on their communities [ 50 ]. Enhancing donor motivation and broadening the donor pool can be achieved by introducing selfie points, allowing donors to share post-donation images on social media. Moreover, leveraging Facebook's blood donation tool, which connects users with local blood centers, could enhance donor retention and overall motivation for increased donations [ 11 ]. Blood donation benefits an individual's health by decreasing oxidative stress and preventing oxidants by increasing antioxidant enzymes such as superoxide dismutase [ 51 ]. Donating blood can also help us improve our emotional and physical health [ 52 ].

Future directions and challenges

Young individuals, typically aged 18-24, have the potential to make a substantial impact in alleviating blood shortages through active encouragement to participate in blood donation efforts [ 21 ]. Research has revealed a spectrum of factors, including attitudes, social norms, perceived control, and knowledge, that influence the willingness of young people in low-income countries to engage in voluntary blood donation, with the potential to enhance blood supply and overall national health [ 53 ]. The future directions and challenges facing blood donation include the need for more diverse donors, the impact of technological advancements on blood transfusion, and the global blood shortage. It could also examine potential solutions to these challenges, such as using artificial blood or expanding blood donor networks. Undergraduate students represent a promising demographic for future blood donation initiatives, presenting an opportunity for increasing the donor pool within the country [ 8 ]. One notable psychological impediment in the context of blood donation is the phenomenon of donation-related anxiety [ 54 ]. Lack of public knowledge and education is one of the main barriers to blood donation. Numerous individuals should understand the significance of blood donation and its role in preserving lives. Future initiatives should focus on informing and teaching people about the value of blood donation [ 6 ]. One way to streamline blood donation processes is with blood donation management software designed to bridge the communication gap between donors and recipients. This application prompts prospective blood donors to register their basic information. The system then notifies donors via messages, requesting their blood donation within a 12-hour timeframe. Such a system can significantly alleviate the challenges faced by blood banks [ 24 ]. Blood donation organizations face the ongoing challenge of attracting and retaining donors. In developing nations, recruiting donors proves difficult, necessitating enhanced access to blood donation programs. Conversely, in industrialized countries, where contributors may be less inclined to donate regularly, there is a critical need to boost donor retention. Future efforts should focus on refining retention and recruitment strategies to guarantee a consistent and safe blood supply [ 55 ]. Maintaining blood donation programs requires ensuring donors' safety. Blood collection organizations must continuously assess and enhance their safety protocols to mitigate the transmission of diseases and prevent other adverse incidents. The adoption of technology can transform current blood donation procedures [ 56 ]. Mobile apps, for example, can help with donor scheduling and recruitment, while artificial intelligence can help with blood demand forecasting and inventory management [ 57 ]. Future initiatives should focus on incorporating technology into blood donation programs to increase their effectiveness and efficiency. The marketing of blood and the discrimination against specific donor groups are just two of the moral and social questions that blood donation poses. The future of blood donation depends on addressing these challenges and implementing innovative strategies to ensure a safe and viable blood supply [ 26 , 33 , 55 ].

Conclusions

In conclusion, raising awareness of blood donation is crucial to saving lives and promoting community health. Modern strategies for raising awareness include projects like planned community events, planned social media campaigns, strategic partnerships with indigenous organizations, and employing the influence of public figures and sports persons to successfully reach and engage a broader range of the population. Nevertheless, continuous endeavors to sustain and enhance donor engagement are in progress. It delivers tailored messages to various demographic groups, offering convenient avenues for donations and tackling prevalent misunderstandings and anxieties related to blood donation.

The authors have declared that no competing interests exist.

Sudden openings and gradual closures in canopy cover modulate acclimation, survival, and growth of a shade-tolerant rainforest tree species

• Original Paper
• Published: 20 May 2024
• Volume 35 , article number  91 , ( 2024 )

Cite this article

• Ana Paula Moretti 1 , 2   na1 ,
• Flavia Yesica Olguin 1 , 2 , 4   na1 ,
• Juan Marcelo Gauna 1 , 2 , 3 &
• Corina Graciano 1 , 2 , 3  

Forest disturbances at gap levels are one of the most important events for the regeneration and establishment of intermediate tree species. Abrupt canopy openings expose plants to high light intensity and high evaporative demands that stress shade-acclimated plants. Later, the slow closure of gaps reduces light availability to plants established when the incident irradiation was higher. This work evaluated the morphological and physiological acclimation of Cabralea canjerana (Vell) Mart. regeneration to sudden and to gradual changes in canopy cover. A pot experiment was carried out with plants exposed to a sudden opening. A few days after the light shock, plants rapidly increased photosynthetic rates and decreased leaf water potential. After two months, plants activated physiological responses at leaf and whole plant levels to high light and water stresses, e.g., increased stomatal conductance, stomatal index and reduction of leaf: fine roots ratio and chlorophyll. After seven months, hydraulic conductivity of petioles and the whole leaf increased, and growth was much higher than plants that remained under the canopy. In a field experiment in gaps in the rainforest, plants acclimated to all canopy covers. Seven years after planting, growth was maximum in open environments within the gaps, even if the canopy closed during the first 20 months after planting. In conclusion, if this species is planted to enrich the rainforest, positions within gaps with lower canopy cover should be chosen and gap closure will not affect growth. To manage C. canjerana natural regeneration, the opening of gaps and removal of understory will increase survival and growth without the risk that the stress caused by these sudden openings could lead to the death of seedlings. Combining pot and field experiments helps to understand the autecology of trees with particular ecological interest, and to build sound restoration practices.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Aimi SC, Araujo MM, Tabaldi LA, Tonetto TD, Zavistanovicz TC, Berghetti ÁL (2020) Shading as a determinant factor for the survival and growth of Cabralea canjerana in Southern Brazil. Cerne 26:349–355. https://doi.org/10.1590/01047760202026032743

Article   Google Scholar  

Amir AA (2012) Canopy gaps and the natural regeneration of Matang Mangroves. For Ecol Manag 269(1):60–67. https://doi.org/10.1016/j.foreco.2011.12.040

Aro EM, Virgin I, Andersson B (1993) Photoinhibition of Photosystem II. inactivation, protein damage and turnover. BBA-Bioenerg 1143:113–134

Article   CAS   Google Scholar  

Berghetti ÁLP, Araujo MM, Tabaldi LA, Turchetto F, Aimi SC, Rorato DG, Marchezan C, Griebeler AM, Barbosa FM, Brunetto G (2020) Morphological, physiological and biochemical traits of Cordia trichotoma under phosphorous application and a water-retaining polymer. J for Res 32:855–865. https://doi.org/10.1007/s11676-020-01132-8

Calzavara AK, Bianchini E, Mazzanatti T, Oliveira HC, Stolf-Moreira R, Pimenta JA (2015) Morphoanatomy and ecophysiology of tree seedlings in semideciduous forest during high-light acclimation in nursery. Photosynthetica 53(4):597–608. https://doi.org/10.1007/s11099-015-0151-0

Campanello PI, Genoveva Gatti M, Ares A, Montti L, Goldstein G (2007) Tree regeneration and microclimate in a liana and bamboo-dominated semideciduous Atlantic forest. For Ecol Manag 252(1–3):108–117. https://doi.org/10.1016/j.foreco.2007.06.032

Campanello PI, Villagra M, Garibaldi JF, Ritter LJ, Araujo JJ, Goldstein G (2012) Liana abundance, tree crown infestation, and tree regeneration ten years after liana cutting in a subtropical forest. For Ecol Manag 284:213–221. https://doi.org/10.1016/j.foreco.2012.07.043

Campoe OC, Iannelli C, Stape JL, Cook RL, Mendes JCT, Vivian R (2014) Atlantic forest tree species responses to silvicultural practices in a degraded pasture restoration plantation: from leaf physiology to survival and initial growth. For Ecol Manag 313:233–242. https://doi.org/10.1016/j.foreco.2013.11.016

Campoe OC, Stape JL, Mendes JCT (2010) Can intensive management accelerate the restoration of Brazil’s Atlantic forests? For Ecol Manag 259(9):1808–1814. https://doi.org/10.1016/j.foreco.2009.06.026

Caquet B, Barigah TS, Cochard H, Montpied P, Collet C, Dreyer E, Epron D (2009) Hydraulic properties of naturally regenerated beech saplings respond to canopy opening. Tree Physiol 29(11):1395–1405. https://doi.org/10.1093/treephys/tpp067

Article   PubMed   Google Scholar  

Carter JL, White DA (2009) Plasticity in the Huber value contributes to homeostasis in leaf water relations of a mallee Eucalypt with variation to groundwater depth. Tree Physiol 29(11):1407–1418. https://doi.org/10.1093/treephys/tpp076

Crawford AJ, McLachlan DH, Hetherington AM, Franklin KA (2012) High temperature exposure increases plant cooling capacity. Curr Biol 22(10):R396–R397. https://doi.org/10.1016/j.cub.2012.03.044

Article   CAS   PubMed   Google Scholar  

Denslow JS (1987) Tropical rainforest gaps and tree species diversity. Annu Rev Ecol Syst 18:431–451. https://doi.org/10.1146/annurev.es.18.110187.002243

Di Rienzo JA, Casanoves F, Balzarini MG, Gonzalez L, Tablada M, Robledo CW (2020) InfoStat versión 2020. Centro de Transferencia InfoStat, FCA, Universidad Nacional de Córdoba, Argentina. http://www.infostat.com.ar

Duan H, Wang D, Zhao N, Huang G, de Dios VR (2022) Tissue DT limited hydraulic recovery in seedlings of six tree species with contrasting leaf habits in subtropical China. Front Plant Sci 13:967187. https://doi.org/10.3389/fpls.2022.967187

Article   PubMed   PubMed Central   Google Scholar  

Felton A, Felton AM, Wood J, Lindenmayer DB (2006) Vegetation structure, phenology, and regeneration in the natural and anthropogenic tree-fall gaps of a reduced-impact logged subtropical Bolivian forest. For Ecol Manag 235(1–3):186–193. https://doi.org/10.1016/j.foreco.2006.08.011

Fracheboud Y, Leipner J (2003) The application of chlorophyll fluorescence to study light, temperature, and drought stress. In: DeEll JR, Toivonen PMA (eds) Practical applications of chlorophyll fluorescence in plant biology. Springer, US, pp 125–150

Chapter   Google Scholar  

Franks PJ, Drake PL, Froend RH (2007) Anisohydric but isohydrodynamic: Seasonally constant plant water potential gradient explained by a stomatal control mechanism incorporating variable plant hydraulic conductance. Plant Cell Environ 30(1):19–30. https://doi.org/10.1111/j.1365-3040.2006.01600.x

Gálhidy L, Mihók B, Hagyó A, Rajkai K, Standovár T (2006) Effects of gap size and associated changes in light and soil moisture on the understorey vegetation of a Hungarian beech forest. Plant Ecol 183:133–145. https://doi.org/10.1007/s11258-005-9012-4

Gandolfi S, Joly CA, Leitão Filho HDF (2009) “Gaps of deciduousness”: cyclical gaps in tropical forests. Sci Agric 66(2):280–284. https://doi.org/10.1590/S0103-90162009000200020

Garbarino M, Mondino EB, Lingua E, Nagel TA, Dukić V, Govedar Z, Motta R (2012) Gap disturbances and regeneration patterns in a Bosnian old-growth forest: a multispectral remote sensing and ground-based approach. Ann for Sci 69:617–625. https://doi.org/10.1007/s13595-011-0177-9

Haworth M, Elliott-Kingston C, McElwain JC (2011) The stomatal CO 2 proxy does not saturate at high atmospheric CO 2 concentrations: evidence from stomatal index responses of Araucariaceae conifers. Oecologia 167:11–19. https://doi.org/10.1007/s00442-011-1969-1

Hernandez Velasco M, Mattsson A (2020) Light shock stress after outdoor sunlight exposure in seedlings of Picea abies (L.) Karst and Pinus sylvestris L. pre-cultivated under LEDs—possible mitigation treatments and their energy consumption. Forests 11(3):354. https://doi.org/10.3390/f11030354

Inskeep WP, Bloom PR (1985) Extinction coefficients of chlorophyll a and b in N, N-dimethylformamide and 80% acetone. Plant Physiol 77:483–485

Article   CAS   PubMed   PubMed Central   Google Scholar  

Kraj W, Ślepaczuk A (2022) Morphophysiological acclimation of developed and senescing beech leaves to different light conditions. Forests 13(8):1333. https://doi.org/10.3390/f13081333

Lavinsky AO, Gomes FP, Mielke MS, França S (2014) Photosynthetic acclimation in shade-developed leaves of Euterpe edulis Mart (Arecaceae) after long-term exposure to high light. Photosynthetica 52(3):351–357. https://doi.org/10.1007/s11099-014-0038-5

Li XN, Wang YH, Yang ZH, Liu T, Mu CC (2022) Photosynthesis adaption in Korean pine to gap size and position within Populus davidiana forests in Xiaoxing’anling, China. J for Res 33:1517–1527. https://doi.org/10.1007/s11676-021-01439-0

Melcher PJ, Holbrook MN, Burns MJ, Zwieniecki MA, Cobb AR, Brodribb TJ, Choat B, Sack L (2012) Measurements of stem xylem hydraulic conductivity in the laboratory and field. Methods Ecol Evol 3(4):685–694. https://doi.org/10.1111/j.2041-210X.2012.00204.x

Mohammed GH, Zarco-Tejada P, Miller JR (2003) Applications of chlorophyll fluorescence in forestry and ecophysiology. Practical applications of chlorophyll fluorescence in plant biology. Springer, US, pp 79–124

Montgomery RA, Chazdon RL (2002) Light gradient partitioning by tropical tree seedlings in the absence of canopy gaps. Oecologia 131:165–174. https://doi.org/10.1007/s00442-002-0872-1

Moretti AP, Olguin FY, Pinazo MA, Graciano C (2019) Water and light stresses drive acclimation during the establishment of a timber tree under different intensities of rainforest canopy coverage. Cerne 25(1):93–104. https://doi.org/10.1590/01047760201925012616

Murphy MRC, Jordan GJ, Brodribb TJ (2012) Differential leaf expansion can enable hydraulic acclimation to sun and shade. Plant Cell Environ 35:1407–1418. https://doi.org/10.1111/j.1365-3040.2012.02498.x

Olguin FY, Moretti AP, Pinazo MA, Graciano C (2019) Morpho-physiological acclimation to canopy coverage of Araucaria angustifolia during the establishment in the Atlantic forest Argentina. Bosque 40(3):323–333. https://doi.org/10.4067/S0717-92002019000300323

Prado K, Maurel C (2013) Regulation of leaf hydraulics: from molecular to whole plant levels. Front Plant Sci 4:51890. https://doi.org/10.3389/fpls.2013.00255

Quevedo-Rojas A, García-Núñez C, Jerez-Rico M, Jaimez R, Schwarzkopf T (2018) Leaf acclimation strategies to contrasting light conditions in saplings of different shade tolerance in a tropical cloud forest. Funct Plant Biol 45(9):968–982. https://doi.org/10.1071/FP17308

Rungwattana K, Hietz P (2018) Radial variation of wood functional traits reflect size-related adaptations of tree mechanics and hydraulics. Funct Ecol 32(2):260–272. https://doi.org/10.1111/1365-2435.12970

Sanches MC, Marzinek J, Bragiola NG, Terra Nascimento AR (2017) Morpho-physiological responses in Cedrela fissilis Vell. submitted to changes in natural light conditions: implications for biomass accumulation. Trees-Struct Funct 31:215–227. https://doi.org/10.1007/s00468-016-1474-6

Smith WK, Berry ZC (2013) Sunflecks? Tree Physiol 33(3):233–237. https://doi.org/10.1093/treephys/tpt005

Szymańska R, Ślesak I, Orzechowska A, Kruk J (2017) Physiological and biochemical responses to high light and temperature stress in plants. Environ Exp Bot 139:165–177. https://doi.org/10.1016/j.envexpbot.2017.05.002

Takahashi S, Badger MR (2011) Photoprotection in plants: a new light on photosystem II damage. Trends Plant Sci 16(1):53–60. https://doi.org/10.1016/j.tplants.2010.10.001

Toca A, Moler E, Nelson A, Jacobs DF (2022) Environmental conditions in the nursery regulate root system development and architecture of forest tree seedlings: a systematic review. New for 53:1113–1143. https://doi.org/10.1007/s11056-022-09944-8

Tozzi ES, Easlon HM, Richards JH (2013) Interactive effects of water, light and heat stress on photosynthesis in Fremont cottonwood. Plant Cell Environ 36(8):1423–1434. https://doi.org/10.1111/pce.12070

Turchetto F, Araujo MM, Tabaldi LA, Griebeler AM, Rorato DG, Aimi SC, Berghetti ÁLP, Gomes DR (2016) Can transplantation of forest seedlings be a strategy to enrich seedling production in plant nurseries? For Ecol Manag 375:96–104. https://doi.org/10.1016/j.foreco.2016.05.029

Tyree MT, Zimmermann MH (2002) Xylem structure and the ascent of sap. Springer, Berlin

Book   Google Scholar  

Valladares F, Niinemets Ü (2008) Shade tolerance, a key plant feature of complex nature and consequences. Annu Rev Ecol, Evol Syst 39:237–257. https://doi.org/10.1146/annurev.ecolsys.39.110707.173506

Vilhar U, Simončič P (2012) Water status and drought stress in experimental gaps in managed and semi-natural silver fir-beech forests. Euro J for Res 131:1381–1397. https://doi.org/10.1007/s10342-012-0605-x

Wright JS, Muller-Landau HC, Condit R, Hubbell SP (2003) Gap-dependent recruitment, realized vital rates, and size distributions of tropical trees. Ecology 84(12):3174–3185. https://doi.org/10.1890/02-0038

Wyka TP, Robakowski P, Żytkowiak R, Oleksyn J (2022) Anatomical acclimation of mature leaves to increased irradiance in sycamore maple ( Acer pseudoplatanus L.). Photosynth Res 154:41–55. https://doi.org/10.1007/s11120-022-00953-4

Zimmermann AP, Fleig FD, Tabaldi LA (2019) Aimi SC Morphological and physiological plasticity of saplings of Cabralea canjerana (Vell.) Mart in different light conditions. Revista Árvore 43:e430103. https://doi.org/10.1590/1806-90882019000100003

Download references

Acknowledgements

We thank the staff of the Campo Anexo Manuel Belgrano, San Antonio, Misiones, Argentina that belongs to INTA EEA Montecarlo for permission to work in their facilities and taking care of the experiments. We thank Martín Pinazo, Fermín Gortari, José Vera Bahima, Santiago Martínez and Mauro Bartolozzi for field measurements in the gap experiment.

Author information

Moretti Ana Paula and Olguin Flavia Yesica made equal contributions to this paper.

Authors and Affiliations

INFIVE (CONICET-Universidad Nacional de La Plata), Diagonal 113 N°495, 1900, La Plata, Provincia de Buenos Aires, Argentina

Ana Paula Moretti, Flavia Yesica Olguin, Juan Marcelo Gauna & Corina Graciano

CONICET, Godoy Cruz 2290, C1425FQB, Buenos Aires, Argentina

Facultad de Ciencias Agrarias y Forestales, Universidad Nacional de La Plata, Calle 60 y 118, 1900, La Plata, Provincia de Buenos Aires, Argentina

Juan Marcelo Gauna & Corina Graciano

Facultad de Ciencias Forestales, Universidad Nacional de Misiones, Bertoni 124 km 3, 3380, Eldorado, Provincia de Misiones, Argentina

Flavia Yesica Olguin

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Corina Graciano .

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Project funding : This project was supported by UCAR, Ministerio de Agricultura, Ganadería y Pesca de la Nación, Argentina (PIA 12010 and 14,031) and ANPCyT-MINCyT, Argentina (PUE INFIVE: 10520180101142CO).

Corresponding editor: Yu Lei.

The online version is available at http://link.springer.com .

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 345 KB)

Rights and permissions.

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Moretti, A.P., Olguin, F.Y., Gauna, J.M. et al. Sudden openings and gradual closures in canopy cover modulate acclimation, survival, and growth of a shade-tolerant rainforest tree species. J. For. Res. 35 , 91 (2024). https://doi.org/10.1007/s11676-024-01736-4

Download citation

Received : 25 January 2023

Accepted : 22 April 2023

Published : 20 May 2024

DOI : https://doi.org/10.1007/s11676-024-01736-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Cabralea canjerana
• Atlantic forest
• Abiotic stress
• Regeneration
• Find a journal
• Publish with us
• Track your research