Ideas and practices around blood, blood donation
and blood transfusion:
A case study in Bamenda, Cameroon
© WHO. All rights reserved
Juliette Koster
Master Scriptie Medische Antropologie en Sociologie Universiteit van Amsterdam
Begeleider: Prof. S. van der Geest Tweede lezer: Drs. Erica van der Sijpt
Abstract
Introduction
This research focuses on the perception of blood, its donation and its transfusion, in the town of Bamenda, Northwest Cameroon. Crucial questions concerning these subjects arise because of the major shortage of blood available for blood transfusion in African hospitals. Existing research in African settings is scarce and unable to supply appropriate models for improvement, because it does not address the crux of the problem: the deep-seated cultural perceptions of blood, its donation and transfusion. The objective of this research is to contribute to the study of perceptions, ideas and practices surrounding blood, its donation and transfusion. Hopefully, this research will contribute to bridging this gap in our knowledge. Ultimately, I aim to contribute to a better understanding of blood donor behaviour and thus to an improvement of blood donation in Cameroon.
Methods
The research is an explorative case study and is framed by a transactionalist and a symbolic-cognitive theoretical perspective. Using only one theoretical framework would lead to insufficient understanding of the total problem. The transactionalistic perspective highlights pragmatic reasons and motivations for blood donor (or transfusion) behaviour, while the symbolic-cognitive perspective provides us with data on the symbolic meanings and cognitive constructions of blood and blood transfusion. Combining these two perspectives will provide a better understanding of the data obtained through the research. The research is partly hospital-based and partly community-based. It focuses on people at three different levels: the donor level (community and therefore possible donors), the recipient level (patients and their care-takers), and the medical staff. The instruments that have been used to generate the data are: in-depth interviews, observation, participant observation, random conversation, and study of digital registration of donors. The main question of the research was: What ideas and practices exist around blood, blood donation and blood transfusion in Bamenda, Cameroon?
The results presented here follow the four sub-questions of the research.
Results
How do 'ordinary' people (care-takers, donors, patients) perceive blood?
Blood is viewed as a vital fluid that people need in order to survive. The symbolic interpretation of blood is a significant aspect of family belonging. Blood is thought to carry traits and characteristics of both families and individual people. Sharing blood, therefore, could mean the (unwanted) exchange of these traits and characteristics. The sight of blood usually means that something is wrong. This presupposition has the effect of blood signifying life as well as death. Blood is perceived as a gift. If a person has enough blood in his body, he has the ability and power to offer it to someone who needs a blood transfusion. The amount of blood in the body is thought to differ between people of different sizes, sexes and appearances. Even though blood is considered to be private initially, in life-threatening situations most people agree on the fact that blood is a communal, or familial, resource.
How do the two main parties involved in blood donation (medical staff and 'ordinary' people) perceive blood donation and transfusion?
There is a shared fear of receiving blood. The consequence of receiving blood from someone with a bad character like a thief will have a negative effect upon the recipient's character. Prominent churches further reiterate the concept of blood having individual significance. Some religious institutions prohibit blood transfusion based on their strict ideas concerning medicine. A blood transfusion is therefore a medical treatment that is thought of as a last resort. The consistent support and preference of traditional medicine leads patients to mix forms of medication and treatment. Mixing traditional and contemporary medicines is considered dangerous and undermines the authority of the hospital. A striking result of this thesis is the emphasis of the notion that blood should be replaced. After the loss of blood, whether as a patient or donor, something needs to be done "to put it back". This thesis has revealed that drinking the juice of beats, herbs, plants and fruits, and specifically Guinness beer, helps stimulate the production of blood cells and is therefore recommended.
What ideas and practices influence people's decision-making processes or donor behaviour?
Donor behaviour is first and foremost influenced by fear of blood donation. A common fear is that the use or misuse of blood serves evil purposes; if one has your blood, he or she can use it to do you harm. People are also afraid of donating blood to a blood bank; the unknown destiny of their donated blood is a major barrier to donate. More than anything, people fear the screening process they have to go through. They believe that finding out one's poor health status could even lead to an early death. Therefore, people look for donors within their families first. Blood that comes from within the family is considered safe and wholesome. Yet, family is no definite assurance for the acquirement of blood neither for a blood transfusion nor for a donation free of charge. In the end, most blood is sold. Shared poverty has led to the general acceptance of the selling of blood. A major part of this market is hidden due to underhand transactions and acts of reciprocity.
What ideas and practices are significant for the different parties involved in the recruitment of donors? And why? The contemporary methods of attracting donors in an African setting are different from those practised in 'western' societies. This research has shown that within the African setting a blood donation is considered a 'voluntary act' when it results from a free will. This does not mean that something cannot be asked for in return. The process of attracting donors by caretakers is heavily influenced by the 'strength' of their story towards possible donors; people need to be persuaded. The shift from the symbolic meaning of blood towards blood as a product can be explained through the pragmatic decisions people need to make when their health is at stake. The value of blood in times of illness is estimated different from its value in times of health. Health is negotiated, because a different scope of meaning implies different consequences. The awareness of the large real risk of receiving an infected blood transfusion is one of the causes of the low incidence of blood transfusion.
Abstract
Dit onderzoek richt zich op percepties en praktijken rond bloed, donatie van bloed en bloedtransfusie, in de stad Bamenda in de Noordwest Provincie van Kameroen. Cruciale vragen over deze thematiek presenteren zich vanwege de enorme tekorten aan bloed voor bloed transfusies in Afrikaanse ziekenhuizen. Bestaand onderzoek in Afrikaanse settings is schaars en niet in staat modellen te produceren om deze situatie te verbeteren, omdat het zich niet richt tot de kern van het probleem: de dieper liggende culturele percepties van bloed, donatie en transfusie. Dit onderzoek hoopt deze leemte in onze kennis te vullen. Uiteindelijk hoop ik bij te dragen aan een beter inzicht in bloed donor gedrag en daarmee aan de verbetering van bloeddonatie in Kameroen.
Methoden
Dit is een exploratieve case-study vanuit een transactionalist en symbolisch-cognitief perspectief. Het gebruik van een enkel perspectief zou onvoldoende inzicht bieden in het gehele probleem. Het transactionalistische perspectief benadrukt de pragmatische beslissingen en motivaties rond bloeddonatie en -transfusie, terwijl het symbolisch-cognitief perspectief ons de gegevens verschaft over de symbolische betekenissen en cognitieve constructies van bloed en bloedtransfusie. Het combineren van deze beide perspectieven leidt tot een beter inzicht in het totaal van gegevens dat dit onderzoek genereert. Het onderzoek is gedeeltelijk in en gedeeltelijk buiten het ziekenhuis uitgevoerd. Het richt zich op drie verschillende niveaus: het donor niveau (de buitenwereld en de daarin voorkomende donoren), het recipiënt niveau (patiënten en hun zorgdragers), en het medisch personeel. De onderzoeksinstrumenten zijn: diepte-interviews, observatie, participerende observatie, willekeurige conversaties en een studie van digitaal geregistreerde bloeddonoren. De hoofdvraag van het onderzoek was: Welke ideeën en praktijken bestaan er rond bloed, bloeddonatie en bloedtransfusie?
Resultaten
De resultaten gepresenteerd in dit abstract volgende de vier subvragen van het onderzoek
Hoe zien en ervaren ‘gewone’ mensen (zorgdragers, donoren, patiënten) bloed?
Bloed wordt gezien als een vitale vloeistof die mensen nodig hebben om te leven. De symbolische betekenis van bloed is een significant aspect van de familieband. Er wordt gedacht dat bloed bepaalde kenmerken en karakteristieken met zich meedraagt, van zowel families als van individuen. Het delen van bloed kan daardoor leiden tot het (ongewild) uitwisselen van deze kenmerken en karakteristieken. De zichtbaarheid van bloed betekent meestal dat er iets mis is. Deze visie heeft het effect dat bloed zowel leven als dood kan beduiden. Bloed wordt gezien als een gift. Als een persoon genoeg bloed in zijn lichaam heeft, kan hij zijn bloed geven aan iemand die een bloedtransfusie nodig heeft. Aangenomen wordt dat de kwantiteit van bloed in het lichaam verschilt tussen mensen van verschillende sekse, gewicht en voorkomen [wat bedoel je]. Ook al wordt bloed in eerste instantie gezien als iets dat privé is, zijn mensen in levensbedreigende situaties het er gewoonlijk over eens dat bloed iets gemeenschappelijks is of iets dat de hele familie toebehoort.
Hoe zien de twee belangrijkste partijen in bloeddonatie (medisch personeel en ‘gewone’ mensen) bloeddonatie en -transfusie?
Er is een wijdverbreide angst om bloed te ontvangen. De consequentie van het ontvangen van bloed van iemand met een slecht karakter of van een dief kan een nadelig effect hebben op het karakter van de ontvanger. Diverse kerken benadrukken deze personalistische eigenschap van bloed. Sommige religieuze instituten verbieden bloedtransfusie vanwege hun kritische ideeën over geneeskunde. Een bloedtransfusie wordt dan ook gezien als een laatste redmiddel. De populariteit van traditionele geneeskunde leidt er bovendien toe dat patiënten vaak traditionele medicijnen mengen met biomedische. Het mengen van verschillende medische behandelingen is echter gevaarlijk en ondermijnt de autoriteit van het ziekenhuis. Een opmerkelijk resultaat van dit onderzoek is het accent op de notie dat bloed vervangen moet worden. Na het verlies van bloed, als patiënt of als donor, moet er iets ‘gedaan worden’ om het bloed ‘terug te zetten’. Dit onderzoek toont aan dat het drinken van het sap van wortelen van planten en bieten, kruiden, fruit en vooral Guinness bier, de productie van rode bloedcellen stimuleert en daarom wordt aangeraden.
Welke ideeën en praktijen beïnvloeden beslissingsprocessen en donorgedrag?
Donorgedrag wordt voornamelijk beïnvloed door de angst voor het donoren van bloed, zoals de angst voor misbruik van bloed; als iemand je bloed heeft, kan hij dat gebruiken om daar je daarmee kwaad te doen. Mensen zijn ook bang om bloed te doneren aan een bloedbank; de onbekende bestemming van bloed is een barrière om bloed te doneren aan een instelling. Het meest is men echter bevreesd voor het testen van bloed. Men gelooft dat het bekend worden van iemands (slechte)gezondheidstoestand kan leiden tot een vroege dood. Daarom zoeken mensen eerst binnen hun familie voor donoren. Bloed dat vanuit de familie komt wordt als veilig en gezond ervaren. Toch is de familie niet een garantie voor het verkrijgen van bloed, of voor een kosteloze donatie. Uiteindelijk wordt het meeste bloed verkocht. Gedeelde armoede heeft ertoe geleid dat het verkopen van bloed geaccepteerd wordt. Een groot deel van deze markt gaat verborgen onder reciprociteit en onderhandse transacties.
Welke ideeën en praktijken zijn significant voor de betrokken partijen voor het rekruteren van donoren? En waarom?
De hedendaagse methoden om donoren aan te trekken in deze Kameroenese setting verschillen van de methoden die worden gebruikt in een westerse setting. Dit onderzoek toont aan dat in Bamenda een bloeddonatie als ‘vrijwillig’ wordt gezien als zij is gedaan uit vrije wil. Dit betekent echter niet dat er niet om een gunst of betaling gevraagd kan worden. Het proces om donoren aan te trekken wordt sterk beïnvloed door de ‘kracht’ van het verhaal dat overgebracht wordt op mogelijke donoren. De verandering van de symbolische betekenis van bloed in bloed als product of handelswaar kan verklaard worden uit de pragmatische houding die mensen aannemen wanneer hun gezondheid op het spel staat. De waarde van bloed wordt in tijden van ziekte anders geschat dan tijdens gezondheid. Gezondheid is aan onderhandeling onderhevig, omdat verschillende betekenissen verschillende consequenties impliceren. Het bewustzijn van het grote risico van het ontvangen van geïnfecteerd bloed is een van de belangrijkste oorzaken van de lage incidentie van bloedtransfusie.
INDEX
METHODEN 3
Preface 7
Chapter One: Introduction 8
1.1 Why this research? 8
1.2 Blood and blood transfusion 8
1.3 Defining the problem 9
Chapter Two: Literature study 12
2.1 Empirical studies involving people's perception of blood and blood donation 12
2.2 Empirical studies involving donor behaviour 14
Chapter Three: Transfusion theory 17
3.1 The Transactionlist perspective on transfusion medicine 17
3.2 The Symbolic Cognitive perspective on transfusion medicine 18
Chapter Four: Methods and design 20
4.1 Study type 20
4.2 Study design 20
4.3 Study population and sampling 21
4.4 Research instruments 23
4.4.1 In-depth interview 23
4.4.2 Focus Group Discussion 25
4.4.3 Participant observation 26
4.4.4 Random conversations 28
4.4.5 Digital registration of (possible) donors 28
4.5 Residence 29
Chapter Five: Context 30
5.1. Cameroon: Political situation 30
5.2 Bamenda 31
5.3 Hospital and Blood Bank 32
5.3.1 The physical appearance of the blood bank. 32
5.3.3 ‘The exchange system’ 34
5.3.4 Government support 35
5.3.5 Hierarchy within the blood bank 36
5.3.6 How are blood donations and transfusions processed and how are donors taken care of? 36
5.3.7 Screening processes for blood donors 36
5.3.8 Screening processes for blood to be issued out to a patient. 37
Chapter Six: Symbolism and semantics 38
6.1 Symbolic meaning of blood. 38
6.1.1 ‘Blood is life’ 38
6.1.2 ‘The visibility of blood means there is something wrong’ 39
6.2 The quantity of blood 39
6.3 The symbolic linkage between blood and family 40
6.4 Blood and character 41
6.5 Blood is a gift 42
Chapter Seven: Perceptions on blood donations and transfusions 45
7.1. The role of traditional medicine 45
7.1.1 Preferring traditional medicine 45
7.1.2 Mixing meds 46
7.2 Replacing the blood 47
7.2.1 ‘Putting it back’ 47
7.2.2 Foods and drinks 48
7.3 The effects of a blood transfusion 49
7.3.1 Weakness 49
7.3.2 Improvement 49
7.4. Fear of receiving blood 50
7.4.1 Strangers 50
7.4.2 Receiving blood from a thief 51
7.5 Religious beliefs 51
Chapter Eight: The effects on and of donor behaviour 53
8.1 Fear 53
8.1.1 Fear of the use or misuse of blood for evil purposes 53
8.1.2 Fear of the blood bank 54
8.1.3 Fear of screening processes 54
8.2 Family donors 56 8.3 Poverty 57 8.3.1 Reciprocity 57 8.3.2 Selling blood 58 8.4 Negotiating risks 60 8.4.1 Risky business 60
8.4.2 Risking a life, saving a life 61
8.4.3 Risking an infection 61
8.5 Helping 62
Chapter Nine: The dynamics of recruiting blood donors 64
9.1 The meaning of a voluntary donor 64
9.2 Persuading 65
9.3 Blood as a commodity 66
9.4 Negotiating health. 66
9.5 Statistics 67
9.6 Sensitisation 67
Chapter Ten: Conclusion 69
10.1 Theory 69
10.2 Most striking results 69
10.2.1 How do 'ordinary' people (care-takers, donors, patients) perceive blood? 70 10.2.2 How do the two main parties involved in blood donation (medical staff and 'ordinary' people) perceive
blood donations and transfusions? 70
10.2.3 What ideas and practices influence people’s decision-making processes or donor behaviour? 71 10.2.4 What ideas and practices are significant for the different parties involved when recruiting donors? And
why? 72
10.3 The input of this thesis 73
10.4 Suggestions for the future: Research and donor campaigns 74
Bibliography 76
Preface
Before I start presenting the result of my Master Thesis, in which I have put a lot of time, effort and even a love, I want to find the time to thank the people who have helped me throughout this process. Research is never carried out alone. Without the assistance of mentors, respondents, informants and even family and friends, this research would have never existed. I have, probably, experienced the usual difficulties a researcher experiences when he carries out his research. However, to me these difficulties were new. I can safely say that my experiences were hard at times. The notes from my diary will demonstrate certain difficulties, I will not elaborate on here.
I wish to start with thanking Sjaak van der Geest, who has followed and guided my since I have initiated this Master thesis. If it had not been for his knowledge and experience, I would have turned in a document nowhere near the quality it bears today.
Also, I want to thank Erica van der Sijpt, for accepting the task to read my thesis and evaluate it with attention on such short notice.
I would like to thank all the people I have worked with in the Provincial Hospital in Bamenda. It is with their help and open attitude towards me that I was able to carry out my work. My special thanks go out to Dr. Franklin Chi. He has provided me with many respondents and made it more accessible to talk to people in the hospital. I am happy that I can soon present this research to the Provincial Hospital in Bamenda in person.
I would like to thank Susanna Graham for editing my writing. Special thought goes out to Marjolein Stapel, for helping me to be critical of my own work and who helped me to improve it, until one should stop editing and let it be what it has become.
To conclude, conducting this research and writing this thesis is the result of many conversations and established relations. I thank everyone who has been a part of this, from beginning to end. I appreciate and respect everyone who has opened up to me and made this research a tremendous experience.
Chapter One: Introduction
‘I recognized one immediately. I also remembered we had dismissed him as a donor because we had tested him positive for Hepatitis. I wondered why he was here.’
My diary
1.1 Why this research?
This research focuses on the perception of blood, its donation and its transfusion. Imperative questions concerning these subjects arise because of the major shortage of blood available for blood transfusion in African hospitals. The high mortality rates that are a consequence of unavailability of blood or the delay in blood transfusion are distressing. The startling poor screening process that donated blood is subjected to may lead to the transmission of infections, such as HIV and malaria. This may affect a population's motivation and decision-making process with regard to donating their blood. The difficulties that are experienced when researching, or indeed motivating (and mobilizing) people to donate blood to an African blood bank lead to the demand for new transfusion policies and practices. Existing research is insufficient in supplying the appropriate models for this improvement, because it does not address the crux of the problem: the deep-seated cultural perceptions of blood, its donation and transfusion.
This thesis is partly hospital based and partly community based and has been conducted in Bamenda, Cameroon. The objective of this research is to contribute to the study of perceptions, ideas and practices surrounding blood, its donation and transfusion. Ultimately, I aim to contribute to a better understanding of blood donor behaviour and thus to an improvement of blood donation in Cameroon.
1.2 Blood and blood transfusion
The subject of my research is, as noted above, the perception of blood, its donation and transfusion. An additional reason for this subject is my personal interest in perceptions, experiences, practices and meanings surrounding blood. Blood is a vital fluid in our body, for without it we would die. Even though we would also die if we were denied other body parts, an essential difference between blood and other parts exist: Blood can easily be lost from the body. At the same time, blood can regenerates itself and can be given away without losing life. Blood contains a person's health and illness. Many countries in the world share this fixation with blood. The meaning and symbols attached to blood are widespread and ever diverse. The seemingly important role it plays in politics, families, tribes, persona and the body encourages me to focus on a specific region: that of, Cameroon. In this context, I will focus on blood's embodiment, significance and value, in order to address a personal fascination with the topic.
Within this study, I am particularly interested in how blood and blood transfusion are experienced by people in Cameroon. Cameroon faces many health problems, including Transmissible Transfusion Infections (TTI’s) caused by blood transfusions. My research was conducted in Bamenda, in the North-West of Cameroon. I
Blood transfusions are a normal part of medicine in western hospitals. However, in African hospitals, blood transfusions are less common in everyday medicine. Lack of transfusion services, lack of trust in these services, lack of equipment, long waiting times for blood and people’s help seeking behaviour are all factors I assume to play a part in the low incidence and quality of blood transfusions in most African countries. However, this does not tell us a lot about the role of lay beliefs and perceptions concerning blood and blood transfusions. Contemporary literature discusses factors that are mostly based upon western research performed in western settings. Little research has been conducted in an African setting. Hopefully, this research will contribute to bridging this gap in our knowledge.
1.3 Defining the problem
The problem is evident. Without blood, some medical interventions are in vain and can cause life-threatening situations. Blood transfusion is a method that can save lives in situations such as trauma, accidents, anaemia, child delivery, etc. Although blood transfusion is mostly used as a supportive treatment, in life threatening situations blood needs to be readily available. The social relevance of a blood supply is apparent; people need blood to survive, to recover, to live. However, blood is not only about life, it also concerns death. Blood suggests a possible end to a life, illness and suffering. Therefore blood assumes a symbolic relevance during social events, rituals, body experiences and indeed in people’s imagination.
In African countries, however, there is a major shortage of blood for transfusions and transfusion services are poorly functioning in most hospitals (Fleming 1997). Many hospitals are neither equipped to perform transfusions nor to safeguard and store donated blood. The shortage of blood for transfusions leads to many difficulties in health care. People who need blood are most frequently children and pregnant woman (Fleming 1997). By denying them access to blood for transfusions this sensitive group continually suffers, both physically and socially. If a doctor issues a blood transfusion, blood is almost never present in the village hospital. It needs to come from outside the hospital, from replacement donors (family and friends) or through paid donors (Von Schubert 1994). The time between the issue of a blood transfusion and the actual transfusion being performed is an average of two days. Within this time many weak patients and children are likely to die. The most important reason for this delay is the ‘quest’ for a suitable donor and the fear of TTI’s. Research has shown that 25 % of the donated blood in Africa is not tested for HIV and 50% is not tested for Hepatitis B and Syphilis. The prevalence of HIV infections caused by blood transfusions is estimated between 10 and 15% in Sub-Saharan Africa (Fleming 1997), and approximately 8-11% in Cameroon (Mbanya and Tayou 2005). Appropriate testing of blood for infections could therefore save many lives.
Little anthropological or sociological research has been conducted examining the relation between the barriers of recruiting donors, the low incidence of blood transfusions and its basis within human perception of blood. It is my belief that patterns of thought, medicine, treatment and traditions are outcomes from cultural
The research question, therefore, is:
What ideas and practices exist around blood, blood donation and blood transfusion in Bamenda, Cameroon?
This question will be approached by dividing this research scope within several sub-fields: - How do 'ordinary' people (care-takers, donors, patients) perceive blood?
- How do the two main parties involved in blood donation (medical staff and 'ordinary' people) perceive blood donations and transfusions?
- What ideas and practices influence people’s decision-making processes or donor behaviour?
- What ideas and practices are significant for the different parties involved when recruiting donors? And why?
These four sub fields will offer merely a framework wherein I will present my research data. The quantity of the data is extensive; by dividing the analysis in these four categories a clarifying analysis is possible. In Chapter Two I will focus on the literature study. Of importance what empirical evidence has already been presented. In addition to this, I will present the two theories I will use to further frame this research: The transactionalist theory and thee symbolic-cognitive theory. Chapter Three offers a brief elucidation of both perspectives and how these perspectives will offer a valid approach for my research. I will present the two theories I will use to further frame this research. I will continue with a presentation of the methods I have used to conduct this research in Cameroon. Chapter Four discusses the study-design, sampling, research population and instruments that have been used. After the research has been framed in the first four chapters, Chapter Five offers an extensive ethnographic elucidation of the context in which this research has been conducted. It presents ethnographic data on the blood bank and all activities that are carried out to keep the blood bank functioning. Then, in Chapter Six I will focus on the perception surrounding blood: Special attention will be paid to the symbolic character and personal interpretations of blood. This will be followed by the perceptions of blood donation and transfusion in Chapter Seven. Here the focus will be on traditional ideas and practices and medicine, notions of the effects of a blood donation and transfusion and the effect of religion on peoples perception of blood donation and transfusion. To continue, chapter Eight concentrates on ideas and practices that influence donor behaviour. It will illuminate major barriers such as fear of witchcraft, the blood bank as institution and receiving blood. It will also elaborate on the role of family donors. It focuses on the influence of poverty and the perception of risk on donor behaviour. Finally, it focuses briefly on the idea of helping someone else by donating one's blood. In Chapter Nine I will
Chapter Two: Literature study
‘How did this happen to this boy?’ Interview with a community member
Preceding researchers, scientists and even hobbyists have constructed tales and ethnographic narratives on ideas and practices surrounding blood, its donation, and transfusion. This chapter focuses on existing literature on blood, its donation and transfusion. The literature study also presents the contemporary knowledge that is used to explain donor behaviour. It illustrates vividly how certain aspects of this research topic have been adequately researched previously, but more importantly how existing literature fails to include significant aspects that influence the problematic shortage of blood, blood donors and transfusions. Preceding literature has engaged in two research scopes; people’s ideas surrounding blood itself: ‘What do we know today about people’s perception of blood and transfusion?’, and on possible motivations that lead to donor behaviour; ‘What motivations do people have on whether to donate blood?’
2.1 Empirical studies involving people's perception of blood and blood donation
The meaning people give to the concept blood is inherently cultural. Culture is as a process in which people give shape to their lives. Ruling ideologies and social relations continuously give shape to this process. Hence, culture also influences people’s body experiences. The experience of the body, whether individually, socially or politically (Scheper-Hughes and Lock 1987), incorporates the cultural beliefs, conceptions, metaphors, symbols and experiences that we have in society. In other words, blood and blood transfusion symbolize relationships between the body and the outside world.
The concept body imagery (Scheper-Hughes and Lock 1987) is useful in illustrating the existing differences in body perception. According to Scheper-Hughes and Lock, organs and other body components capture the imagination of people. Capturing the imagery (or imagination) of blood (whether physical or psychological) tells us not only how the body is viewed in different cultures, but also how bodies are experienced and how they relate to the outside world. Anatomical conceptions help us to understand perceptions of health and illness. Body imagery therefore presents social dimensions of anatomical perceptions and their collective representations. The possibility of a collision of body imagery between an individual experience and a collective experience might be interesting, because of the implications this brings about for transfusion policies.
Besides fluctuating perceptions of the body, blood and blood transfusion, medicine itself constantly develops as well. The chance of someone having an experience with transplantation or transfusion medicine is also ever increasing. Hence, more and more people have an experience with giving a part of their body away, or receiving a part of someone else’s body as part of a medical treatment. Waldby et al. (2004) describe the ‘giving and receiving’ of one’s body and suggest that this act might also be ‘lived’ as giving and receiving a part of one’s self. To some extent, some people believe their blood contains a small part of their identity. This concept, identity,
Previous research conducted on blood shows how blood is often a key cultural symbol. Seeman explains in his research how blood forms a person's identity; it is perceived as life (Seeman 1999). To distinguish between our body and that of others, when considering blood and blood transfusion, Waldby et al (2004) have introduced the concept Bioidentity. This concept describes our (common sense) conceptions of our body as supporting our ‘self’, but also as our relation (inclusion) to the subjective and social identity. With the determination of ourselves, we also determine our boundaries. Our skin connects us to the world. Nevertheless, the relation between our self and the (our) world is dynamic. How people perceive this relationship between their blood and the outside world is therefore an interesting question. The term bioidentity is a dynamic concept, a constant friction between the self and the social. Or in this context better stated: between donor and recipient (Waldby et al. 2004). This constant friction might explain why people do not act upon their intentions to donate blood. A constant battle between one’s perception of blood as part of the self and simultaneously as a communal resource might hinder one’s donating behaviour.
In addition, in African countries blood, as a concept, is known to contain many symbolic meanings. An empirical study in Marseille, France, has shown how for Comorian people blood means a tie through which they are bound to their family. They refer to it as their blood identity. This corresponds with Waldby’s et al. concept of bioidentity that describes blood as a resource that is perceived to have traits of character that are family specific. A blood transfusion can therefore mean creating an unwanted or ‘unnatural’ tie between people (Grassineau et al. 2007).
Other empirical studies display how blood can carry multiple meanings. Ingham demonstrates, in his explanations of Mexican folk medicine, how peasant societies categorize blood as one of the four humours in the human body; warm and moist (Ingham 1970). Mexican peasants fear losing blood because, according to their beliefs, blood is not easily regenerated. Common understandings of blood as a non-regenerative bodily fluid are well described by Foster in his theory of the Limited Good. He states how peasants understand their blood as being present in finite quantities. Losing blood means losing blood forever, a permanent loss, resulting in weakness (i.e. illness). This concept of blood as a limited good might be helpful, in understanding donor behaviour.
Apart from body imagery, there are also external factors that influence ideas and practices surrounding blood donation and transfusion. Even though the ideas surrounding blood transfusions are old, the actual applications of it in public health practices were long awaited. Biological, anatomical and technical developments were all necessary in order for it to be put into practice (Giangrande 2000). The technology of blood transfusion itself incorporates many cultural perceptions. The machines, the action, the instruments, being aware of the process as it is taking place, all have an effect on the experience of blood transfusion. The technology alienates the blood from its donor. It makes it ‘un-self’. At the same time it can make the blood one’s own through the same device and action. Chliaoutakis and colleagues describe how donor facilities and services can influence one’s
So far, blood has shown to be a cultural concept that influences body imagery and more specifically, anatomical conceptions. The fact that more and more people have an experience with blood transfusions initiates a discussion about exchanging blood and thus the giving and receiving of body parts. In some cases, the literature demonstrates how blood is perceived to contain one’s identity and personality. The relation between the ‘self’ and the outside word is therefore a dynamic concept, one that challenges people’s perception of the body, the individual and family. The literature, furthermore, has focused on describing the fear of losing blood in rural areas and the permanent consequences it carries. Finally, the progress the transfusion technology is subjected to is of influence on people’s body perceptions and how it is dismantled through technological development.
2.2 Empirical studies involving donor behaviour
Addressing the second question we find how in different cultures different motivations lead to blood donation. Most research on motivations to donate blood has been performed in Canada, Europe and USA, leaving Africa open for further research.
Grassineau and colleagues (2007) stress that in France, the very act of blood donation derives from the notion of altruism. This concept illustrates mainly European motivations; it is a shared resource (or commodity) to which everyone should have access. Giving blood is seen as a natural act. It seems likely to find unambiguous notions of blood in other European countries. However, it is uncertain whether the same notion is shared in African countries. People who have had many experiences with blood, for example people with Haemophilia, particularly share the notion of blood as a resource. Waldby et al. (2004) have found in their research this group of people tend to perceive their blood as a communal resource.
Yet these beliefs are shared only by a small group of people. Lay beliefs towards blood and its donation and their subsequent influence upon behaviour are difficult to obtain and understand. Researchers therefore seem to prefer studying behaviour itself rather than perception. Godin et al. state that the Canadian society can be divided into two groups of possible donors; those who have never donated and those who have had an experience with donating before. The group who have had an experience with blood transfusion seem to be more willing to donate blood (Godin et al. 2005). Experience, for once, seems a major motivation to give blood. Mbanya and Tayou (2005) also stress in their update on blood donors in Cameroon, that the experience of donating blood (for a relative or example) motivates people to become regular donors. Rather than targeting a community as a whole, experienced blood donors, possibly, offer a more certain target.
When taking a step back to consider first time blood donors, a question that comes to mind is: which people donate blood and with what motivations? This brings us to a difficult discussion in the literature, as Von Schubert vividly presents; the debate whether blood donation should be voluntary or whether blood donors should
The question of whether a donor should give blood voluntarily, or whether he should be paid, raises the question of what a marketplace for blood would mean for patients and health care. When patients start paying donors, what would determine the market price? How is this decided and what effects would this have on policy, insurance etc? Therefore the concept blood as a commodity is crucial for this research (Von Schubert 1994). When researching people’s motivations for blood donations, it is important to address financial issues (i.e. income, costs, urgency, delay), because this might influence people’s donor behaviour. If people view their blood as a commodity, the perception of blood might differ from people who do not see their blood as a possible product. These attitudes and perceptions might furthermore influence the market place, such as blood trade (as a part of organ trade for example) and could have a great affect on the way people perceive their blood and bodies.
Motivations to donate blood are influenced by the concept of risk. Heron et al. (2004) stress that risk is a social construct and that lay people and physicians perceive risk in different manners. The writers argue that the quantity of risk perceived in a given situation is disproportionate to the determination of whether that risk is too high. A second important element is that people will perceive a risk in a manner that is easy to imagine or to recall. A third essential component of the risk concept is the notion of risk as heterogeneous, even within the same community. This perceptual diversity needs to be researched not as perceptions in isolation but as perceptions in relation to one another (using a multi-level perspective), because these perceptions are created within the same social structure.
Perceived risk leads us to the notion of perceived control. Personal motivations regarding whether to donate blood are influenced by an individual's perceived control. Grassineau et al. researching in Marseille, found that the Comorian community expressed fear about the fate of the donated blood. They were concerned their blood would be used for evil purposes, or by the French to further marginalize their minority (Grassineau et al. 2007). In Godin et al.’s study of factors determining donor behaviour he stresses how perceived barriers (i.e. location, health status, transfer etc.) also have an effect upon donor behaviour. If the perception of control is increased, so does the intention to donate blood (Godin et al. 2005).
These studies have addressed the motivations for blood donations, emphasizing the western altruistic characters of donations. The act of donating is furthermore influenced by prior (positive) experiences. It has been demonstrated that regular donors form a group that can be targeted by campaigns more easily. The first time donor is described within the debate of voluntary and paid donors. The donor might address his blood as a shared
Chapter Three: Transfusion theory
‘An ounce of action is worth a ton of theory’ Friedrich Engels (1820 - 1895)
The two major theories that are used to frame this research and categorize its results are; Transactionalism and Symbolic-Cognitive theory. A valid anthropological study normally engages itself with a certain theoretical approach. Yet, it became apparent to me that a single theory would be insufficient to explain all the ideas and practices surrounding blood, its donations, and transfusion, if possible at all. The complexities of all the factors that influence structural cultural perceptions regarding donor are too extensive to appropriate to one theory. The challenging task at hand is therefore to use two theories to steer the research and interpret its findings.
3.1 The Transactionlist perspective on transfusion medicine
Frederik Barth introduced Transactionalism in the twentieth century, who stressed that social organization is created through actions of reciprocity, such as exchanges and transactions. Barth emphasized that within social organizations (which includes medicine) individual decision making processes form a consistent pattern of choice. More specifically, this approach argues that individuals act so as to increase and maximize their gain (O’Barr 1977). This approach states culture, as well as health and illness, as a result of social competition. Also, transactionalism can be used to examine more profoundly the way disease can be negotiated. For instance, people will try to obtain an advantage from their disease. As useful as this theory might seem, criticism, in my opinion, is rightfully at place. If all individuals would engage in gaining and maximizing, then this indisputably results in growth at the expense of others. This approach stresses agency to be very important, for it is the individual who makes the decisions. However, agency is not a separate entity. It is inherently connected to structure, because structure always plays a part in decision-making; Institutions, medical staff, friends and family influence one's individual decision-making. Therefore, every decision-making process involves relations between structure and agency. As mentioned above, Barth's original theory stresses the individual to be solely concerned with his personal gain. With regard to the intertwined concepts of structure and agency, a challenge would be to sensitize this primary form of Transactionalism.
The idea of individuals mediating, negotiating and maximizing their health, using pragmatics, seems obvious in the field of blood transfusion. Patients in need of a blood transfusion are generally in a poor health state. The transactionalist perspective states that people will make the best decision for themselves depending upon their particular status. In other words, they will take on a pragmatic attitude: People will consider what is at stake, and how their personal situation can be improved. If a transfusion will bring him personal gain, he will probably decide to be transfused. The transfusion, or transmission, of blood can be considered a form of transaction. Receiving blood from someone else, implies either accepting blood or paying for blood to receive a transfusion. Either option depends upon a blood donor.
3.2 The Symbolic Cognitive perspective on transfusion medicine
Cognitive Anthropology focuses on the analysis of cognitive processes and systems of belief. It engages itself in the analysis of classification and categorization and how to achieve an accurate representation of a culture or society. The ways people talk about events are most relevant here. Likewise, the way people construct their society intellectually is very important (Colby et al. 1981). Symbolic anthropology on the other hand, has engaged itself in studies of metaphor and symbolic modes of social. In comparison to symbolic anthropology, cognitive anthropology seems more static and more in search of models. Symbolic anthropology seems to be in search of the much wider context and representation of events (phenomena, experiences, rituals etc.).
Combining the symbolic and cognitive approaches results in a theory that applies ethnographic methodology on mental processes to study cultural problems, relations, practices, symbols and meanings (Colby et al. 1981). When considering blood and blood donation and transfusion, the symbolic-cognitive approach is a valid theory due to its illumination of symbolic interpretations and perceptions and the cognitive constructions in which they are created. The relevance of symbolic anthropology to my research constitutes itself in its interest in relations between private and public symbols and realities. Just like the relation between structure and agency described in the Transactionalism theory, the public and private symbols and realities are interconnected and under constant negotiation. The structural influence on the formation of our private decisiveness implies that our agency is merely a symbolic agency, although in the individual mind it is perceived as exclusively individual decisiveness nonetheless.
Blood is one of the most deep-seated symbols in culture and body experiences (Scheper-Hughes and Lock 1987, Grassineau et al. 2007, Seeman 1999). Its meaning is negotiated in its relationship between the self and the other, structure and agency and the private and the public. Authors like Geertz and Schneider (in Colby et al. 1981) have argued that a cultural system, as well as the normative within this system, can be best understood through the knowledge of its symbols and their constitutive powers. Even though it seems appealing to ascribe all interpretations of phenomena to the symbolic meaning of things, it is not evident that the meaning of blood as a symbol exclusively can tell us all about a society. Blood cannot only be defined in a symbolic manner; it is also a tangible bodily fluid. Even the meaning of this bodily fluid can be interpreted in more than one way. Accordingly, blood can carry multiple meanings on different contextual levels. As a matter of fact, blood presents a good example of the problematic relationship between a concept and its physical manifestation.
Chapter Four: Methods and design
‘What do you mean someone declared it to be another public holiday?!’ My diary
4.1 Study type
This research is an explorative case study. Two important reasons for this study type can be mentioned. First of all, the existing literature is not sufficient to initiate a discussion that includes all possible factors that influence donor behaviour. Secondly, because of the little time available, this research cannot claim representativeness for any specific group or locality.
A substantial part of the research is hospital-based. I have spent most time in the hospital, examining the existing transfusion service and being present in the blood bank. In the first place, I choose this research context to understand how contemporary transfusion services are put into practice. Relevant questions that arise are ‘What happens in the hospital?’ and ‘What relations are essential? Since contemporary literature does not adequately addresses this sort of questions, creating a practical and accurate ethnography on the hospitals transfusion practices are of special importance for this research. Understanding the daily practices and activities of staff and visitors, will help shaping an accurate image of transfusion medicine in an African setting. This knowledge is new, since most academic legitimate studies have been done in Western settings. Contemporary research in African setting, on the other hand, mainly focuses on the prevalence of TTI’s or poor policies around transfusion services.
I have experienced that carrying out this research in a hospital based setting, specifically has been a demanding task. This is inherent to the explorative character of the study, as the data shows merely an overall impression. Many hours have been spent on a chair or bench observing. I was present every day the first five weeks. The second part (four weeks), I was present frequently. The data collected is the result from many notes, summaries, annotations and interpretations.
In addition to the hospital-based fieldwork, I carried out community-based research as well. This constituted an important part of research, as it focussed mainly on the perception of blood, its donation, blood transfusion and donor behaviour. My presence within the community was especially necessary, since most visitors and caretakers passed as community members and a lot of conversations and interviews were consequently held on the hospital premises. On some occasions respondents were found outside the hospital. These were hazardous respondents, established through contacts within the hospital, in the surrounding of my residence or through coincidental meetings.
4.2 Study design
The design is a multi-level perspective. Sjaak van der Geest and colleagues introduced this perspective in 1990, opposing the dominant single-level research in anthropology. This perspective proposes to research subjects
With this research, I aim to contribute to the understanding of three different levels of perception; the donor level (community and therefore possible donors), the recipient level (patient and care-taker), and the medical staff. The multi-level perspective views concepts of illness as negotiable and its meaning as constituted through pragmatics. Insight in the flexibility of the meaning of concepts have encouraged me to view concepts and phenomena not as fixed systems of meaning, but as adaptable and variable phenomena, in constant relation with the level of health care and what is at stake for people. This approach frames the two theoretical perspectives in the research. It will be used as an instrument to analyze the constant transformation of the concept blood, donations and transfusions.
4.3 Study population and sampling
The multi-level perspective facilitates the possibility to research multiple populations. The research has focused on three levels, as stated above. These levels define the three research populations; medical staff, caretaker and the community. At the first level (medical staff), a substantial part of the research has been carried out within the hospital. Consequently, the hospitals physicians and health workers were a primary research population. Amongst the medical staff, nurses appeared to be of much help. Although it took a while before everyone was adjusted to my attendance, I was received friendly. I noticed that the staff needed some time to accept my every day presence, by the way some conversations would end or start, or by the way nurses would move around in the blood bank physically. I made sure that I attended all gatherings and events for personnel. I displayed interest in their personal
Initially, the second group was supposed to represent the patients in need for a blood transfusion. However, in practice, the patients who need a blood transfusion appeared too sick to talk or to answer questions for an interview. When in need for a blood transfusion, their conditions are usually grave. The contacts that were established existed principally of short acquaintances and moments of acknowledging the severity of a situation. Patients rarely visit the blood bank. Hence, the second population shifted from patient to care-taker, for it is the care-taker that is present in the blood bank, looks for blood among its peers and receives the blood from the bank. On countless occasions I have felt compassion for the burden on the caretakers shoulders to find suitable donors. Their job to replace blood that is handed to them for ‘their’ patient is handled with care and attention. The caretakers proved to be a good research group. Even though the conversations with them were usually short of nature, they were very resourceful and useful. Many of them were either eager to talk to me about their problems and experiences or eager to kill the time they needed to wait in the blood bank. Their role within this research was significant. It did not seem to be at first, since the importance of their role as caretakers became comprehensible in the field. It was interesting though, how quickly their significance became apparent and I turned to them as a research population. Nevertheless, including this group also had its drawback. A negative consequence of these conversations was that they frequently wanted to talk to me, because of the fact that I’m white. This posed problems on directing the conversation towards usable research data. Personal questions about my life and personal problems within theirs recurrently overshadowed the conversations. It was a challenge to redirect them towards a conversation that could be used for this study. Also, the short character of these conversations made it difficult to reach certain profoundness within these dialogues.
The third research group exists of possible donors or differently put, the community. This population was the hardest to access. Even though they were present on a daily basis in the bank, they were reluctant to talk about their status as possible donor. The obstacles to talk to them became evident through barriers such as language and my position as a white researcher. Many of the respondents only spoke Pidgin English. Even though it seems similar to English that is spoken in Anglophone countries, many words and sounds differ; it was therefore difficult to understand each other. Also, many respondents were shy. I felt that a substantial part of them were impressed by my presence, by the way people would simply avoid me, or oppositely, trying to get my attention. A part from language barriers, I had difficulties with understanding many people, in terms of behaviour and the will to speak to me, and this difficulty was mutual. Scheduled meetings were often cancelled due to the fact that the respondent would not shop up. I would have trouble understanding why people made certain decisions (for example, concerning the group in which they would look for blood donors, or where). In addition, my ‘whiteness’ and possibly my status as a young female researcher made many respondents feel uneasy to talk to me. The fact of being white was brought up frequently and, also, the differences this implied between the respondent and me as a researcher. However, when my confidence grew as a researcher, my conversations with this population became
Through snowball sampling I hoped to find more respondents. This form of sampling is known to be convenient in case of a tight time-span, or difficulties finding respondents. Though many people were willing to talk about their problems, their problems in the end were theirs and little was shared among caretakers or families within wards. The snowball effect eventually failed, because few families knew each other well enough and it was difficult for one to find another willing respondent. I altered the sampling technique into randomly approaching people who entered the blood bank. I did not differentiate between men and woman or age etc.; this led to a diverse list of respondents. People visited the bank for multiple reasons. Some come and donate, others look for results of blood tests, looking for blood, bringing in donors etc. Hence the type of conversations varied accordingly the type of respondent.
The change to a different sampling technique brought about positive progression. It became easier to find respondents and it became easier to communicate with them in a shared comprehensive manner. Of particular importance was the contact I established with an employee of the blood bank. This person became a key informant. With his help I could talk to nurses, patients and (possible) donors in the bank and hospital wards, and witness transfusions. I became skilled to collect blood from patients and (possible) donors and talked to people who were waiting for results of tests. This relation was complicated at times by different interests and expectations of work relations, but has shown to be very valuable. The random sampling techniques and the contact established though my key informant resulted quickly in a more extensive ‘respondent pool’.
4.4 Research instruments
When writing the first outline for this thesis, it was vital to think of the kind of research instruments that will be used to get the most resourceful data. My anthropological instinctive mind immediately proposed the following first three instruments as the appropriate and desirable instruments to conduct the data in Bamenda, Cameroon. Halfway through my research I started to realize that the actual in-depth interviews that took place were few. I became concerned whether the data I was collecting would be sufficient enough to present a valid work. For this reason, I decided to introduce two additional methods: a form of random conversations and a digital registration of possible blood donors.
4.4.1 In-depth interview
The semi-structured interview resulted in generally coherent interviews. The results could be analyzed more easily, because of the topics that had been selected in advance. However, the initial idea was to establish non-structured interviews. The anthropological character of this kind of interview has shown itself to be of great value and offers significant validity to generated data gathered through interviews. In practice, it became clear that some guidelines were needed. In first instance because, many respondents had never thought of the topics in that matter or talked about it with their environment. It was necessary to have some questions prepared, supple forms of
A well-organized and effective In-depth interview requires time, attention and a tranquil and safe surrounding. Hence all in-depth interviews were planned with care. The time-span was usually set on an hour or more and most often the interviewee invited to my residence. It was cancelled on numerous occasions by the interviewees. Reasons for cancellations varied and were frequently not even mentioned. Overall, every respondent cancelled at least three times. Some were never interviewed. And in cases of interviews with people I most definitely wanted to see, I ultimately displayed irritation and organized tight and tough new conditions. In these last cases the respondent would certainly show up.
The following fragment will demonstrate the effect of the cancellation of interviews on my research.
My diary: I headed to the hospital, because there was supposed to be a meeting at 08:00. At 8 no one was there. I asked a nurse on duty where the meeting was held and she replied: “A meeting? Ah yes, there was supposed to be. No there’s not today.” I asked how that could be and she replied that it was declared another public holiday. I almost choked on it: “what do you mean someone declared it to be another public holiday?” She said the president had come on the radio Thursday afternoon (Labour Day) and declared this Friday another public holiday. It was okay to stay home today, since they usually take the day off when two public holidays are parted by one regular day. Saturday’s and Sunday’s are also labelled as public holidays. Hence none of my two interviewees showed up today or even called...aarrgghh'.
Due to these unforeseen cancellations and postponements, I became worried not to have sufficient in-depth interviews at the end of the study. I was expecting to execute at least five or six interviews for all three populations each. My concerns grew as I realized that this number of interviews might not be the achieved. In the end four interviews were held within the first research population (medical staff), two interviews were held for the second population (care-takers) and four interviews were held (one of which was a double-interview), for the third research population (the community). In summary, a total of 10 in-depth interviews were conducted
A problem I faced was that the amount of interviews spread over all three populations was imbalanced. The fact that respondents from the caretaker population are less represented within the actual in-depth interviews generated could lead to a bias in my results. A specific research population might suggest specific outcomes. With the limited presence of one of the three research populations it is possible that my results are limited too. The character of the caretaker population group was easy accessible, but not for this kind of interview. I therefore decided to initiate an alternative research instrument, more suitable for this group. This will be further elaborated on in paragraph 4.5.1.
