Factors associated with donation frequency among new and experienced blood donors: health literacy, knowledge, attitudes, fear and motivation

Background. Romania's voluntary, non-remunerated donors give repeatedly, and national policy has recently expanded material incentives, yet whether repeated donation brings a better grasp of who may donate, and what distinguishes frequent from infrequent donors, is unknown. Among Romanian donors reached through a national blood donation application, we asked whether donation experience is associated with eligibility knowledge and with fear, whether knowledge tracks acceptance of blood from specific groups, and what independently correlates with donation frequency, including material incentives against intrinsic motivation. Methods. This cross-sectional survey ran in a national donor application, 13 July to 1 October 2025, among users aged 18 to 65 who had donated since 2023. It used the Romanian HLS-EU-Q16, a knowledge scale (31 items after review against national eligibility regulation), and motivation, attitude, fear and pain items. Of 1,646 respondents, 1,489 passed an attention check; analyses used chi-square, analysis of variance, correlation and hierarchical regression. Results. Respondents were experienced, 92.3% having donated at least twice. Health literacy was high (14.50 of 16) and knowledge moderate (70.1% correct). Knowledge did not differ by donation experience (η² < .001), whereas fear was lower among experienced donors (η² = .084); women knew more and feared more than men but donated less often (d = 0.30, 0.33 and 0.59). Knowing a rule went with accepting blood from eligible groups and refusing it from deferred ones. Adjusted for demographics, frequency rose with lower fear (β = −.144), stronger intrinsic motivation (β = .066) and higher knowledge (β = .060), fell with interest in health-related incentives (β = −.093), and was unrelated to health literacy (β = .012) or material incentives (β = .055; R² = .219). Donors ranked free blood tests highest among incentives (6.13 of 10, 45.7% rating them 8 or above) and meal vouchers and refreshments lowest (4.24 and 3.88). Conclusions. Among app-registered donors, experience was accompanied by less fear but no better eligibility knowledge, and health information outweighed the material incentives policy has expanded. Donor education should be delivered at every donation, fear reduction concentrated on first-time donors, and incentives built on the health monitoring donors already value.