Rethinking the role of older donors in a sustainable blood supply

Many countries, particularly high human development index countries, are facing the challenge of an aging population.1 For Blood Collection Agencies (BCAs) in these countries, an aging population poses two key problems. First, the loss of an increasing proportion of their donor base as donors “age out” of donating. Second, a projected exponential growth in demand for blood products as populations age and disease burden increases, of which many diseases (e.g., cancer) likely require treatment with blood-derived products.2-5 Historically, increases in demand have been met with initiatives to either reduce demand (e.g., patient blood management)6 or increase supply.4 With limited initiatives occurring to curb demand further,7, 8 BCAs need to increase supply. However, as Tran and colleagues noted in their recent commentary,8 while we teeter on the precipice of increasing demand for blood products, participation rates in donating are falling.8, 9 Thus, there is growing concern about the ongoing sustainability of the blood supply. Donor recruitment campaigns have historically been targeted at the young.2, 10, 11 The assumption underlying this approach is that younger donors are more likely to be healthy and have a long donor career.12-15 Yet, younger donors are not an all-encompassing solution. As noted, in many countries there is an aging population, meaning that the proportion of the population who are young is diminishing.1 Further, in this cohort, and in cohorts who are middle aged, the decline in participation in blood donation is particularly pronounced (e.g., 16–24 years,8 17–35 years,16 25–49 years,3). Those recruited from these cohorts are less likely to return and have higher rates of deferral (i.e., be ineligible to donate) than other donors.2, 10, 12, 17, 18 Further, the assumption that younger donors will have a long donor career does not consider the reality that these donors increasingly face. While younger donors have always been time-poor with limited availability to donate, the casualization of the workforce may exacerbate this trend, with United States survey data finding that 47% of Gen Z respondents reported having three jobs.8, 9, 15 In 2023, 36% of US workers identified as part of the gig economy (i.e., casual, flexible employment outside the scope of full-time or part-time employment), with this proportion expected to increase to 50% by 2027.19 The net effect of holding multiple jobs and time invested at these multiple jobs means that younger and middle-aged people are increasingly time-poor.19 Further, donors' careers are not continuous, with donors lost to the competing demands of study, work, family, and/or carer responsibilities.8, 20 In contrast to younger donors, donors aged 50 years and older are a potentially more productive cohort. While literature focusing on this cohort of donors is sparse (a point we revisit below), and 50+ years is a broad age range within which much diversity is observed in how people age,21, 22 the productivity of this broad cohort of older adults is borne out when both life-stage and statistics are considered. Adults aged 50+ years represent a life-stage during which people may become more aware of, or have capacity to prioritize, blood donation. For example, some adults may be approaching a time in their life where childcare responsibilities are diminishing, and other caring responsibilities have not yet fully emerged (parents and/or grandchildren). They may be considering, planning for, or actively transitioning out of work (part-time work, retirement), and/or moving to a retirement living community. This life-stage is an ideal time to “plant the seed” for including blood donation as part of their lives or routine, as a new or returning donor. Even if they do not have the personal resources or capacity now, they may do so in future. Older adults may also increasingly be exposed to loved ones, friends, and acquaintances who need blood/blood products, and these experiences could elevate the importance of donating blood in their awareness, and ultimately their desire to donate blood when they have time. Donors aged over 50 years demonstrate increased growth, higher donation frequency,3, 8, 9, 14 consistent contributions over time,2 and fewer adverse events.18, 23 Older first-time donors also have higher rates of return than other first-time donor cohorts (e.g., >80% return of donors aged 60+ years vs. 62% <40 years).11 Despite these positives, relying on older donors as one of the ways to ensure the ongoing sufficiency of the blood supply has not yet been widely considered (cf. Goldman and colleagues).24, 25 This limited consideration may, at least in part, be due to the debate that has raged around whether “old” blood is of poorer quality than “young” blood.26, 27 However, results regarding the impact of donor age on recipient outcomes are not consistent in observational studies, with several studies showing no significant associations with donor age and recipient mortality.28-31 To date, no clinical trials exist that examine the impact of donor age on recipient outcomes,28 thus the debate continues. Alternatively, aging and older donors are often positioned in the literature as undergoing an inevitable decline where older people transition to become recipients of blood products, rather than donors.3 While statistics may support this perspective,32, 33 many older people age well.24 Yet, excluding workplace or team-based initiatives that may include older adults, older people generally are not typically targeted as first-time donors for mass recruitment by BCAs in marketing campaigns.34 Older adults also do not seem to spontaneously start donating, with only 6% to 13% of adults aged 50+ years beginning their donation career at this age.18 Rather than viewing the “aging out” of donors as problematic, or older adults as recipients rather than donors, it is perhaps time that BCAs instead consider older donors as a potential core strength of their donor base.9 Acknowledging that individuals at different ages and life-stages likely have varied personal resources and capacity, donors aged 50 years and older are a largely untapped resource for recruitment given most campaigns focus on younger audiences.34 Revisions by BCAs to upper age limits for donation,24, 34 and the removal of the variant creutzfeldt-jakob disease (vCJD) permanent deferral criteria in a number of countries,35-37 also mean an increase in the number of donors in this older cohort who may be eligible to donate. Older donors are a dedicated and growing cohort, with increasing healthy-life expectancy and, potentially more time availability (for those with reducing caring responsibilities or at a life-stage enabling part-time work or retirement), who have the potential to sustain the blood supply in the short–medium term.9, 38, 39 Understanding older adults and what motivates and deters them from donating is critical to ensuring their ongoing participation and ultimately the sustainability of the blood supply. However, consistent with their neglect as a cohort of donors, little research has been conducted that is specific to older adults as donors. None has focused exclusively on donors who began donating aged 50 years or older. This limitation is compounded by the fact that what is known about this cohort is largely derived from questionnaires completed by older adults who have donated. We lack an understanding of what may motivate older adults who have never donated to begin, and what may motivate older adults who donated only once or twice in their lifetime to return. Semi-structured interviews with donors, non-donors, and lapsed donors would go some way to alleviating this knowledge gap and providing key information to underpin recruitment strategies for older donors. The few studies available, including those that made age comparisons between existing younger and older (50+ years) donors, provide us with some insight into what may particularly motivate this group of donors. Broadly, these can be categorized into contextual factors (e.g., perceived need for donations, helping others),40-45 perceived personal resources to be able to donate (e.g., having time or being in good health),38, 43, 44, 46 and their own personal needs (e.g., wanting to do something useful).38 The barriers reported by older adults and donors can be broadly categorized into personal resources and organizational factors. The personal resource barriers identified to date typically center on health and relate to anticipated (e.g., feeling old, tired) and actual health conditions or physical limitations,38, 47-51 or the perceived impact of donating on health (e.g., fainting, dizziness, needle stick site).38, 43, 49, 50, 52 However, some older adults note that due to their lifestyle commitments they are (still) too busy to donate.38, 43, 50 Consistent with other groups that have historically not been the focus of recruitment efforts (e.g., African American donors),53 organizational barriers comprise issues of access to donation opportunities (e.g., center location, lack of public transport),47, 54, 55 and the perceived bureaucracy surrounding donating (e.g., arbitrary age limits, lack of effective engagement with donors).24, 38, 48, 56 For older adults, health appears to be a central theme in both encouraging and deterring donation; those in good health feel they should donate, and those who have poor health or anticipate a health impact of donating do not donate. Yet, the degree to which perceived and actual health truly impacts donation decisions needs more intensive exploration in older adult populations.57 Older adult and donor perspectives on the broader intersection between aging, health, and donation are also likely important in determining willingness to donate, but an exploration of this is currently lacking in the research literature.57 Overall, our understanding of what motivates and deters older donors, and specifically older adults who begin (or return after a long-term lapse) to donate, is limited. No research has focused on these cohorts. Nor has there been an exploration of whether motives and barriers to donation differ within older age cohorts based on individual characteristics or circumstances (e.g., age, gender, ethnicity, work status, socioeconomic status), or cultural norms within or across countries. Thus, we acknowledge that our commentary and examples given below may not apply to all older adults (e.g., those aged in their 50s), and may be specific to some ages or life-stages only (e.g., those who are retired and/or have reduced caring responsibilities). It is also not known whether motives and barriers change over time as donors become more experienced or donate different products. However, despite these gaps in our understanding, insights from the limited literature suggest that blood donation could serve an important function for older adults. Models of psychosocial development58 position a need to be useful as part of generativity (i.e., concern for, and acts that promote the well-being of, future generations)59, 60 which is a challenge that adults in mid-life are proposed to face as they age.58 Adults in later life may also possess a desire to be or feel useful (i.e., inner desire) which is proposed to be one of several key motivational sources for generativity.59, 61 Older adults who frequently feel useful compared to those who rarely feel this way have shown better health trajectories,62 and those who have persistently high versus low feelings of usefulness have decreased mortality risk.63 Thus, for those who need to feel useful, have more capacity, and who feel able, blood/blood product donation could fulfill this inner desire to feel useful and contribute in a way that does not require a time-intensive or long-term commitment (unlike traditional forms of volunteering), and may potentially have indirect health benefits. Donation enables a positive and valued contribution to the community by helping those who need blood/blood products,40 and the act of donating may signal to older adults that they are healthy and aging well through their continued eligibility to donate.34, 64 Like volunteering, blood donation enables older adults to continue contributing to society,65 and the oft-cited warm glow after donating is not only critical for blood donor retention,66 but can also contribute to positive self-perceptions while aging. Further, blood/blood product donation may provide social benefits. For some, donation provides them with an opportunity to socialize (e.g., through conversations with staff),67 connect with friends or friendship groups (e.g., donating together),68 or be part of a workplace team or initiative. Maintaining social connections and integration may increase available support, build social capital, reduce loneliness, and protect older adults against morbidity and mortality.68, 69 Donation as an activity may also foster community mobility as donors access blood collection locations via driving or public transport, and community participation as they combine their donation with other activities (e.g., shopping for groceries, coffee with friends). Community mobility and participation in turn contribute to improved mental and physical well-being and quality of life.70 However, the potential for BCAs to stem social disconnection or loneliness and improve self-esteem and well-being in older adults is unexplored, and the role of blood donation in facilitating aging well is unknown.34 Despite the positive benefits that older adults donating may yield for both the blood supply and for this cohort of donors, older adults may not feel welcome or wanted by BCAs. Upper age limits for donors vary significantly between countries34 and this variation results in some older donors perceiving these age limits as arbitrary.24, 38 Further, a lack of effective communication and a lack of solicitation with this cohort excludes potential donors.48, 56 The focus on the young in recruitment campaigns highlights the need for BCAs to be more inclusive of older adults and address any resulting misperceptions that exist about age eligibility requirements. Similar to adults from ethnic and other minority populations, older adults, especially those from migrant or ethnic minority backgrounds, may not see themselves represented in recruitment campaigns and therefore fail to connect themselves as similar to others who donate.71 Co-design with older adults from diverse backgrounds to develop age-relevant recruitment materials is likely needed to promote inclusiveness, provide relevant exemplars, and address barriers to participation of older adults who wish to be donors.72 In addition to not feeling wanted or needed, some older donors may also uniquely perceive a personal need to retain their blood. That is, they may perceive that they cannot spare it,49, 71 or believe that donating will lead to accelerated aging, loss of vitality, permanent weakness, and anemia.73 Reflecting the exclusion of older adults from donating other substances of human origin, and the historical application of upper age limits for blood donation, older adults may also think their blood is inferior to that of younger donors.74 Beliefs related to the quality of the product and the impact of donating may be shaped by gender and by culturally specific understandings of the impact of aging on the body.57 Alternatively, these beliefs may originate in commonly held associations between aging and physical decline that extrapolate to assumptions about blood donation as unsafe for older people,34 ultimately resulting in older people perceiving that they have limited efficacy to donate. Educational outreach by BCAs in community settings frequented by older adults may go some way to addressing any misperceptions about donating blood at an older age and alleviating older adults' concerns. Once BCAs successfully communicate to older donors that they are not only wanted but needed, the challenge then becomes ensuring that these first-time (or long-lapsed) donors have a good donation experience. It is well established that a positive donation experience increases the likelihood of donor return, and experiencing anxiety, adverse events, and deferrals are all deterrents.75 However, in contrast to research focusing specifically on the management of younger donors (e.g., decreasing vasovagal reactions VVRs and interventions to improve retention),76 there is an absence of research exploring the specific experiences and management of older donors. It may be that these and other previously identified factors such as a convenient of donor and in and reduced are important for older donors as they are for other with are also a key quality and less lead to donor In one age in with the blood donation older donors years) compared to younger donors of first-time less with such as the donor and of the good or positive donation is not the absence of a experience. to reduce and may foster a more donation for donors. For low such as (e.g., reduced no or providing or (e.g., a or on the can contribute to a and less for that to the donation experience by increasing personal with also more at a positive experience for first-time donors and increasing their and of first-time older donors is also likely critical so that their experience is Those who blood/blood product donation as an opportunity for social may have the of a and Yet, these of connections are typically by donors who are with or who donate with and may also it to these in a where donor is often a key these insights as they apply to older donors are we do not what the donation experience is for donors aged 50 years and older or what a good experience for this cohort. While donor adverse impact the of a positive donation the of blood donation appears by aging comparisons of donor based on age have been these comparisons typically categorized older donors as those aged over or In a for across countries, older donors years) compared to donors aged Older donors also or similar rates of with loss of compared to the in the younger age group older donors have been shown to blood loss as as younger donors and are less at of compared to younger of donor rates have a more for age, donor and/or collection and that decreased with age of collection or donation experience. However, when the of and age reactions typically low at to be higher in donors aged over Similar rates of reactions observed for older years) and younger blood with or donors aged years and older higher of experiencing these events, of collection and reported that with returning years) donors higher rates of younger and new years) donors higher rates of younger groups compared to younger donors higher rates of Thus, there are new about adverse events, particularly in older donors aged over that first-time and older donors about the potential and this information into blood donor eligibility these and that donor may vary across age older donors as a broad cohort to be able to donate with a likelihood of than younger donors that they have many good years of While age in and of does not lead to deferral from blood donation, donors can become or ineligible to donate (i.e., for a range of the of these issues occurring increases with age and is likely more in donors aged over Thus, including increasing of older adults in the donor (e.g., removal of upper age limits, may also lead to increased deferrals in this age Older donors, compared to younger donors, are more often or at similar rates for below the or other (e.g., their to the donor Older adults years and are more likely to be or for conditions such as and compared to younger can have a impact on donors' well-being and deferrals may lead to or long-term donor For donors who of deferral but not limited and While the to deferral is likely to the for the it is also that the to deferral is with the personal importance of donation to the As being able to donate may have for older adults in of their as healthy and contributing to and their social Consistent with being may have more for older donors' well-being than for younger to can have significant impacts on older people and need to be and by BCAs if more older adults are to start donating. However, research exploring the impact of deferral on older donors is needed, while that most older donors will not be BCAs face increasing in the blood supply due to aging populations and growing demand for blood products. efforts have focused on younger based on the assumption that they will have donor However, participation in blood donation by these younger cohorts is In older people represent a largely untapped resource as donors, have high return in donation, and fewer adverse Despite some around that older donors are healthy to the blood supply. Further, being a blood donor can provide older people with a of ongoing health, and social all of which contribute to reducing morbidity and However, many older adults do not see themselves as the of recruitment efforts by and there is limited understanding of their specific and for their donor experience. these knowledge gaps to improve the donation experience for older donors will them feel the blood and foster positive outcomes for both donors and for the of blood products, and to the community. access by The of as part of the The of via the of The do not have any of to