Formative Evaluation to Inform Recruitment and Engagement Strategies for emergency activation of blood donors in Nimba County, Liberia

While donations from voluntary non-remunerated donors are preferred, approximately 14% of blood donations globally come from family replacement and paid donors. In low- and middle-income countries, the proportion is higher, averaging 36.6% in low-income countries. However, much less is known about family replacement and paid donors relative to voluntary non-remunerated blood donors. It is known that family replacement and paid donors are often activated in response to an emergency in areas where blood is scarce and whole blood is the standard for transfusion. Thus, they are part of de facto civilian walking blood banks. Interest in civilian walking blood banks is increasing, but many operational best practices have not been established. The objective of this study was to better understand the motivations and donation experiences of family replacement and paid donors, as well as their attitudes toward possible donor-facing walking blood bank practices. Semi-structured interviews were conducted in Nimba County, Liberia, in May 2026 with participants who had donated blood in the last twelve months. Recruitment was conducted through radio announcements and snowball sampling. Transcripts were analyzed via directed content analysis using the Exploration, Preparation, Implementation, and Sustainment framework. Twelve donors, 11 men and one woman, participated. Many reported making donations both as family replacement and as paid donors. Participants reported altruism, positive past donation experiences, and a desire to help their families as donation facilitators. They reported distance, concern about pre-transfusion testing, and expenses incurred as donors as barriers. While they reported widespread concern about the effects of blood donation on the donor's health as a barrier to establishing a more formal walking blood bank approach, they typically believed outreach at community institutions would be an effective way to recruit new donors. These findings suggest that continued engagement among established donors in addition to recruitment of new donors is likely to increase the blood supply, although implementation questions around the best approaches to donor compensation and ensuring potential donors are paired with the closest facility remain.