“They don’t want our blood”: Social inclusion and blood donation among African migrants in Australia

Social Science & Medicine 73 (2011) 336e342

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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

“They don’t want our blood”: Social inclusion and blood donation among African migrants in Australia Michael Jay Polonsky a, *, Bianca Brijnath b, André M.N. Renzaho c a

School of Management and Marketing, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia Department of General Practice, Monash University, Australia c Population Health Strategic Research Centre, Deakin University, Australia b

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 13 June 2011

The current study examines how feelings of social inclusion influence migrant communities’ predisposition to donate blood, focusing specifically on Sub-Saharan African communities in Australia. We begin by explicating the theoretical links between social inclusion, citizenship and blood donation before discussing local and international perspectives of blood donation among African migrant communities. Using qualitative methods comprising nine focus group discussions, held between March and April 2010, we argue that blood donation intentions are mediated by whether or not individuals feel included in their new host society. Real and perceived discrimination experienced by African migrants in their everyday social interactions or in institutional settings can act as a barrier to blood donation. We conclude that removing such barriers, thereby increasing rates of donation in migrant communities, will help to build social capital and inclusion. Strategies for how this can be achieved are outlined. Ó 2011 Elsevier Ltd. All rights reserved.

Keywords: Australia African migrants Blood donation Discrimination Race Social inclusion

As a result of wars, poverty, and human rights abuses, there has been a significant increase in the number of refugees and migrants moving from low- to high-income countries (International Organization for Migration, 2005). Australia is one of the countries experiencing relatively high levels of resettlement which has resulted in increased cultural pluralism. Nearly 44% of Australians are either born overseas or have one parent who was born overseas (Australian Bureau of Statistics (ABS), 2007). Since the mid-1990s Sub-Saharan African migrants have been arriving in Australia. While currently comprising less than 1% (192,000 people) of the population, they are one of the fastest growing communities in Australia (ABS, 2007) and in other developed countries (International Organization for Migration, 2005; Konadu-Agyemang, Takyi, & Arthur, 2006; Mott, 2010). Excepting white South Africans and those from Zimbabwe, the majority of Sub-Saharan Africans (hereafter referred to as African migrants) are refugee and humanitarian entrants to Australia under the UN Refugee Convention (Renzaho, 2007). Like other migrants, African migrants come from diverse pre-migration conditions and socio-cultural backgrounds that often lead them to present with complex health needs and to choose different health-seeking

* Corresponding author. Tel.: þ61 3 9244 6968. E-mail address: [email protected] (M.J. Polonsky). 0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2011.05.030

behaviours (Brijnath, Browne, Halliday, & Renzaho, 2011). Consequently, there is a risk of delayed treatment, especially among those of non-English speaking backgrounds who tend to present to health services only when their health condition is very severe (Burnett & Peel, 2001). Although delays in health-seeking are not unique to Australia’s immigrant populations (Manderson & Allotey, 2003), the challenge for the Australian health system, like any migrantreceiving country, is to be responsive to these multiple therapeutic modalities to ensure good health outcomes for the entire population. Addressing migration-related health inequalities can also create social inclusion and the capacity to participate in the community (Moran & Simpkin, 2000; Popay et al., 2008). In this paper we use the case of blood donation to explicate how feelings of social inclusion affect intentions to donate among African migrant populations. Previous studies reveal that blood is a particularly symbolic product in African communities, believed to be a conduit for personality traits, defining kinship, and connecting donor and recipient long after it has left the donor’s body (see Geissler, 2005; Grassineau, Papa, Ducourneau, Duboz, & Chiaroni, 2007; Ottong, Asuquo, Olaniran, Duke, & Abia, 1997; Weiss, 1998). Such beliefs are not necessarily abandoned with migration and shape attitudes to donation and donation experiences in Australia (see, for example, Polonsky, Renzaho, & Brijnath, 2010). In this paper we are specifically concerned with how African migrants’ experiences and

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perceptions of exclusion and discrimination within Australia are related to their intentions to donate blood, the prevailing norms and values around race and donation, and how the process of donation itself is shaped by the wider social context in which Africans and Australians interact. Migration and donation in Australia On arrival in Australia, many African migrants have physical health needs, some of which require blood transfusions, for example, non-immune haemolytic anaemia and haemoglobinopathies. In addition, many women experience pregnancy and birthing complications due to haemorrhage and harmful traditional practices such as female genital mutilation (Beutler, 2008; Mehta, Mason, & Vulliamy, 2000; Natoli, Renzaho, & Rinaudo, 2008). Migrants’ participation in blood donation benefits the needs of the wider community and migrant groups, especially if migrant populations have blood types that cannot be sourced from the local community (Grassineau et al., 2007). With only 3% of the eligible donor population actually giving blood, Australia has one of the lowest rates of donation in the developed world (Reid & Wood, 2008). Most Australian donors tend to be Caucasian, in their fifties, and with blood types that are often incompatible with the blood requirements of some migrant communities (Flood, Wills, Lawler, Ryan, & Rickard, 2006). Thus, it is critical that migrants be engaged as blood donors to meet the blood needs of their own communities and to become more interwoven into their new country of residence. Migrants tend to have very poor rates of blood donation (for blood see Flood et al., 2006) and related behaviour such as organ donation (for organ donation see Morgan, Mayblin, & Jones, 2008). Determining factors include socio-cultural barriers and the extent to which migrants feel included in Australian society. Researchers have found that African migrants who participate in community activities have a broader sense of social inclusion and wellbeing (Correa-Velez, Gifford, & Barnett, 2010). Alessandrini (2005, 2006, 2007) found that Australian blood donors generally had higher levels of community participation, greater tolerance of diversity, stronger connection to family and friends, and greater feelings of trust and security compared to non-donors. While not explicitly tested, she also suggested that engaging in blood donation could lead to broader social inclusion (Alessandrini, 2007). However, her group comparisons precluded testing whether donation led to inclusion or vice versa, did not focus on non-donors’ views of social inclusion, and excluded migrants’ views. Yet, migrant groups culturally or demographically different from the Australian community tend to experience greater difficulty integrating and engaging with social institutions than migrants perceived to be culturally or demographically similar (Colic-Peisker, 2005). For peoples of colour, this is especially important because historical and cultural remnants of the White Australia Policy potentially still influence some community views on the inclusion of migrants from non-Caucasian countries (Jupp, 2002). Social inclusion, citizenship and blood donation Substantial evidence indicates that social exclusion linked to racism, stigma, discrimination and unemployment is damaging to health and reduces access to health services (Baum, 1999; Zwi & Alvarez-Castillo, 2003). Creating socially-inclusive societies where people feel accepted and able to participate in formal and informal institutional activities helps people to build meaning in their lives, network with others, access resources, improve their own capacities and has been found to improve an individual’s sense of wellbeing (Correa-Velez et al., 2010). It has been acknowledged that

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reducing global inequalities begins with social justice, social inclusion and community cohesion (Popay et al., 2008). Social inclusion has political resonance in Australia and numerous initiatives mandate building a “fairer Australia” (Commonwealth Government of Australia, 2010). Defining social inclusion is difficult, with research tending to focus on social exclusion not inclusion (Percy-Smith, 2000). Popay et al. (2008, p. 33) suggest that social exclusion is “a ‘state’ in which people or groups are assumed to be excluded from social systems and relationships”, whereas, social inclusion could be described as an ability to participate in activities. Inclusion and exclusion can apply to all societal activities. Social exclusion is an important issue in accessing healthcare either because programs are exclusive in their design, community members believe programs exclude them, or community members believe programs do not focus on their unique needs (Moran & Simpkin, 2000; Popay et al., 2008). Across countries, social inclusion is positively correlated to blood donation (Alessandrini, 2006; Kolins & Herron, 2003). In Australia, nearly one-third of donors view blood donation as a way “to give something back”, an act of social responsibility and a way to meet one’s obligation to the community (Alessandrini, 2007). However, research has suggested that some people expect a relational benefit from donating (Copeman, 2009), hence facilitating a sense of reciprocity with those who receive the blood, whether they are known individuals or society more generally. This relational benefit might also relate to the fact that within some communities (including many in Africa), blood donations are sourced by recipients or their family members from known people in the community or within the family (Tagny, Diarra, Yahaya, Hakizimana, Nguessan, Mbensa et al., 2009). There are hidden moral sub-texts to altruism. Titmuss (1971), in his seminal study of blood donation, showed that there were few acts of donation based on “pure altruism”. Rather, blood donation was a form of “creative altruism”, a way to fulfil one’s sense of obligation and to feel part of society by gifting one’s blood to the larger body politic. More recent anthropological work reveals further complex linkages between donation, altruism, citizenship and national identity (see, for example, Cohen, 2001; Cooper, 2008; Morgan et al., 2008). Specifically, blood donation is imagined as a way to build social continuities between donor-citizens and their nation-state. For example, Copeman (2004, 2009) found that in India blood donation was a way to publicly commemorate the anniversaries of the death of assassinated politicians and promote ideas of national integration. In Sri Lanka, against the backdrop of war and political unrest, discourses on ethnic identity, kinship and nationalism were woven together to encourage donation (Simpson, 2009). Among the Navajo in the United States, donated or infused blood was used to demarcate tribal and non-tribal members, and accepting non-Navajo blood was seen to defile Navajo peoples, cause sickness and even death (Schwarz, 2009). Grassineau et al. (2007) found that among some African migrants there was also a preference to give to members of one’s own community, and that receiving blood from outsiders was perceived as potentially risky. Thus, there is an implicit bio-morality behind the decision to donate which may or may not have purely altruistic underpinnings. In some instances, the gifting of blood offers a way for citizens to literally become a part of their nation, imagine a link between countrymen who could be “blood brothers”, and to feel socially included and part of the political process. This might explain why some research into blood donation has found that pre-existing relationships could be strengthened by blood, with people more willing or likely to give to their family members, tribe members or countrymen (Tagny et al., 2009). Blood donation is also imbued with economic value to be exchanged for cash or medical services (Copeman, 2009). In some

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African countries there is a perception that corporations and multinationals use blood donation to economically exploit local peoples (Fairhead, Leach, & Small, 2006; Geissler & Pool, 2006; White, 2008). Anxieties about blood being stolen, wasted or misappropriated have travelled with some African migrants. Grassineau et al. (2007) found that Comorian migrants in France perceived blood to have kinship and tribal value and feared that their blood was being sold or misappropriated by the blood service. In Israel, Ethiopian Jews mistrusted the blood service because, in the past, their blood had been discarded expressly because they were from Africa (Merav & Lena, 2011). Concerns regarding the misuse of blood could result in lower levels of trust in the medical system overall, and in lower levels of engagement with the medical system (Gilson, 2003), including blood donation. US research has attributed low rates of donation among African-Americans to their fear and distrust of the health system, as well as the perception that marketing and education strategies were not targeted to the needs of African-Americans (Shaz & Hillyer, 2010). Potential African-American donors are also more likely than potential white donors to expect an item and/or gift for donating (Glynn, Kleinman, Schreiber, Zuck, Combs, Bethel et al., 2002) and to report bad treatment by staff (Schreiber, Schlumpf, Glynn, Wright, Tu, King et al., 2006). It is possible that such negative perceptions could also be present in the Australian setting for African migrants. A national inquiry by the Australian Human Rights Commission (2010) found that African migrants face significant difficulties in accessing housing, employment and education, largely due to racial discrimination, negative stereotyping and prejudice from the wider Australian community, which create real barriers to economic and social inclusion. The study sought to ascertain whether the way wider society views African migrants impacts on migrants’ desire to donate blood and their perceived level of social inclusion. Methods From March to April 2010 nine semi-structured group discussions were undertaken to understand barriers and enablers to blood donation among African migrants. Three focus groups were undertaken in regional Victoria and six in urban Melbourne. Two groups were with young people (16e24 years), four were singlegender groups (individuals 25 years and over), and three were mixed-gender groups (individuals 25 years and over). Work with Sub-Saharan African communities in Australia has found that single and mixed-gender focus group discussions yield comparable and robust data when the issue being researched relates to traditional values (Renzaho, 2009). Inclusion criteria for the study were that participants were members of an African migrant or refugee community and at least 16 years old, which is the minimum age for blood donation. Participants were not required to meet other donation eligibility criteria (Australian Red Cross Blood Service (ARCBS), 2011a lists the general exclusion criteria). While there are no explicit prohibitions on donating associated with people who have lived in Africa, they might have been exposed to illnesses that preclude them from donating (Tagny et al., 2009). Their past and present donation status was also not considered when recruiting focus group participants. The study was governed by a lay person’s steering committee (African Review Panel) and an expert review panel. The African Review Panel, comprising community leaders from various African communities, assisted with recruitment and community mobilisation (Renzaho, 2009; Wilson, Renzaho, McCabe, & Swinburn, 2010). Focus group discussion participants were purposively sampled using existing networks such as soccer clubs, women’s groups, and community and other religious organisations

associated with African communities (Renzaho, Green, Mellor, & Swinburn, 2011). In total, 88 participants were recruited. Issues identified in the blood donation literature (e.g., culture, kinship, economics) were explored via semi-structured, openended questions and prompts to elaborate on particular topics (Bajramovic, Emmerton, & Tett, 2004). The questions focused on attitudes towards blood and blood donation; the influence of cultural and religious norms on donation; blood donation experiences at home and in Australia; and general views about barriers and facilitators towards blood donation. To overcome language barriers among non-English speaking participants, discussions were facilitated by trained bilingual workers who translated questions and answers. Answers were then repeated back to the participants through translators to ensure that the translation captured responses. All three authors were also involved in the discussions. Each discussion took about 60e90 min and was recorded and then professionally transcribed. Respondents were offered a $15 gift voucher to participate in the study. Thematic analysis was undertaken using a constant comparative method (Ryan & Bernard, 2003) and identified themes were then incorporated into NVivo for further coding and final analysis. The researchers read the transcripts and identified themes, which were then compared and further refined until consensus was reached, in-line with recommendations for qualitative health research (Pope, Ziebland, & Mays, 2000; Thorne, 2000). All data have been de-identified to ensure participants’ anonymity. Ethics approval was obtained from Deakin University and the Australian Red Cross Blood Service. Results and discussions Participants comprised migrants (38 percent) and refugees (62 percent) from more than ten African countries (e.g., Sudan, Eritrea, Ghana, Congo, and Burundi). 48% of the sample were 25e40 years old, 31% were under 24 years, and only 13% were over 41 years (8% did not give their age). There was an approximately equal distribution of men and women. The most common languages spoken were English (58%) and Arabic (24%), though many African languages were also spoken in the group discussions (e.g., Kirundi, Lingala, Dinka, Swahili). While we did not ask how long people had been in Australia, according to the Australian Bureau of Statistics (2007) African migration to Australia surged from the late 1990s onwards. There were four themes related to social inclusion: (1) experiences of racism in social settings; (2) medical mistrust and experiences in the Australian health system; (3) blood and disease; and (4) experiences of donating blood in Australia. Experiences of racism in social settings Echoing previous research findings on African communities in Australia (Colic-Peisker & Tilbury, 2007; Correa-Velez et al., 2010; Manderson & Allotey, 2003), participants in this study said they lived in a wider context of racism and discrimination. Many felt marginalised and excluded in the media representations and public discourse of Australian society. One Nigerian migrant (male, 25þ, urban) said, “Here in Australia, I can’t really see any ethnic person in the mainstream.” Another said: Do you know, if they put the advertising on TV about Red Cross [blood service], why can’t they show like multi-culture, why do they only show like white people? (Male, 16e24, rural, refugee from Sudan) Feelings of exclusion were related to direct experiences of racial discrimination. Respondents talked about being mocked in public,

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spat on, and abused on the basis of skin colour, because they “stuck out” as being different to the white majority (Colic-Peisker, 2005). One participant (male, 25þ, urban, refugee from Congo) undertaking volunteer work at a local aged care centre was told by an elderly resident, “I don’t want a black.” Another recounted how he had been assaulted in Melbourne: I was just very new in the country and I was going for lunch . A guy, who had probably had too much of alcohol, he came out of a bar, and he came over to me, an elderly guy, and he was assaulting me. He was hitting me, hitting me hard, and he was saying, “Black man, go back to your country, black man” (Male, 25þ, urban, migrant from Nigeria).

Medical mistrust and experiences in the Australian health system Discriminatory events were also encountered in institutional settings, including the health sector. Respondents talked about experiencing poorer treatment and longer waiting times compared to other patients, receiving insufficient information about their diagnosis, prognosis and treatment, and being made to feel contagious. A Burundian woman (25þ, urban, refugee background) recalled how when she miscarried her third child, an unsympathetic hospital staff told her, “You need to go home and raise these two children, they are enough for you.” Similarly, another participant reported that when she was asked to sign documents, the pen she used was “picked up in a way that looks like it’s very contagious and they will throw it in the bin and pick another pen. So, if you have that, if you’ve experienced something like that, then you have a feeling that even your blood will not be accepted” (Woman, 25þ, urban, refugee from Burundi). One participant expressly identified a perception that the Caucasian population would not accept African blood. Many concluded racist and discriminatory views meant that, “White people can’t accept the blood from Africans”, and there was little point in donating: If you sort of feel that you are being treated unfairly or unjustly and not as a human being, then that does not give you any urge to do anything meaningful for the community in which you live. (Male, 25þ, urban, migrant from Ghana) I reckon some people don’t donate blood because they feel like they’re not Australian. They feel like they don’t, they’re not where they belong. (Male, 16e24, rural, Sudanese, refugee background) Links between blood donation and a sense of belonging and social inclusion resonate with previous findings (see Alessandrini, 2005; Shaz & Hillyer, 2010). Echoing previous studies on African migrants (Grassineau et al., 2007; Merav & Lena, 2011), respondents wanted to donate but did not want any of their blood to be wasted. Respondents were keen to assist those in need, regardless of the recipient’s race or ethnic origin. Blood donation was perceived as a humanitarian act, necessary to save a life, and to be freely given - a finding also made in other studies (Shaz, James, Demmons, Schreiber, & Hillyer, 2010; Titmuss, 1971). Even the Burundian woman who felt she had been badly treated by health staff after her miscarriage said, “In regard to donating blood, I’m ready now. If I were asked to give blood, I would just go and donate blood. I’m fine with it” (Woman, 25þ, urban, refugee from Burundi). Blood and disease Participants’ experiences of discrimination encompassed social marginalisation in employment, income, education and media and

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bodily marginalisation, resulting in a perception that their blood would not be wanted. Participants believed that high rates of HIV/ AIDS and other infectious diseases in Africa were extrapolated by most Australians who assumed all Africans carried disease and were, therefore, ineligible to donate blood: My friend from Australia, she said, “You’re African, you can’t [give blood] because the people are afraid of you. You might have AIDS”. She said that. So, that’s why the Australian people don’t ask us about the blood. They think we have AIDS. (Woman, 25þ, rural, refugee from Congo) Sometimes I think white people won’t be comfortable with black blood . I guess they won’t like it . half of them think Africans got a lot of diseases and all that. (Man, 16e24, rural, refugee from Sudan) For participants, such attitudes were buttressed by existing policies and procedures in institutional arenas, where staff reinforced the image of Africa as a continent rife with disease. The perceptions of some doctors: They think, “Oh, that fella (sic) is sick, he has got some tropical diseases.” So, that perception is still there and there is no need for us to go and donate the blood. (Man, 25þ, rural, refugee from Sudan) African communities’ lack of donation was, at least in part, related to the assumption that they would be deferred from donating because of wider community perceptions of Africans carrying blood-borne diseases, even though being from Africa is not a reason for automatic donor deferral (ARCBS, 2011a). Such assumptions were based on more general experiences of discrimination in Australia and overseas. Yet, as one participant pointed out: They can’t say it’s [diseases] from Africa because we’ve already had tests and why didn’t it appear there? So, if we got any disease here, we know it’s from Australia. (Woman, 25þ, rural, refugee from Congo) Some respondents recognised that ineligibility to donate could also be because of pre-existing health conditions, which could compromise the safety of the blood supply. Health information campaigns for deferrals e for reasons like potential exposure to Creutzfeldt-Jakob Disease (CJD, or Mad Cow Disease) or anaemia e had impacted on participants (i.e., people who have lived in the UK for more than six months between 1980 and 1996 are unable to donate (ARCBS, 2011a). But these respondents did not make links to more specific illnesses that might have been contracted in Africa (for example, those identified in ARCBS, 2011b). A few did not donate blood because they were ineligible: People from African background, because of the hardship they live all the time, they have chronic anaemia and that is not to recover just very shortly when you arrive in Australia . We keep rehabilitating ourselves but it doesn’t correct, go to that level where we could feel the possibility of giving blood. (Man, 25þ, urban, refugee from Burundi) Experiences of blood donation in Australia The recruitment process did not focus on past donation behaviour. However, of 88 people in the sample, four had successfully donated blood in Australia (i.e., 4.5% of the sample, which is higher than the donation rate for the general community). Three of the four were young people who had donated as part of a blood drive initiative at their school or university. Their decision to donate was incidental, that is, the proximity of the mobile donation unit, peer participation and the offer of incentives motivated the young people:

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I did it because one day I was at uni and they had a big van saying, “Come and donate blood”, and they said that they would give you good food afterwards and so I went. (Man, 25þ, urban, migrant from Ghana) The remaining donor, a refugee of Congolese background, was motivated by altruistic intentions, “I get this peace and this protection [in Australia] and I say to myself, ‘What can I give back?’” He had donated blood on several occasions but, at the time of the group discussion, had stopped donating. He explained this was because he felt discriminated against when he went to donate: She [nurse] said, “There are some categories of people who can’t give blood. those who come from Sierra Leone or African countries.” I say, “Yes, I’m coming from those people.” “So you have been donating blood?” I said, “Yes.” “That’s a bit strange,” she said it in a low voice, “it’s strange,” and I asked why. She talked to me about mosquitoes, about everything that is bad in that side [Africa] and, okay, by respect I give blood that day but.I stopped giving blood. (Man, 25þ, urban, refugee from Congo) Other respondents had similar experiences with the blood service, both overseas and in Australia, which perceived them as being diseased because they were from Africa: They think you are HIV positive so as a result you are rejected outright. Even if you volunteer to go, they wouldn’t take you, they wouldn’t accept it. And sometimes even when they try to be sort of like very diplomatic about it, and maybe accept it, at the end of the day it will not be utilised. (Man, 25þ, urban, migrant from Ghana) I once went to the Red Cross to give blood. The lady there, she thought I was lost. But I wanted more information. She thought I had missed the op-shop next door to buy second-hand clothes and sent me there. Then she called the manager to talk to me. So there is a negative perception. They have to handle people better. If I get treated like that, why will I go back? (Man, 25þ, rural, refugee from Sudan) These experiences suggest that even when African migrants do go to donate, negative perceptions of them impact on how they are treated, although the perceptions could be related to the health screening process, rather than there being a racial foundation. One might have anticipated that workers in the health field would be more accepting than those in the wider community, and would have a greater desire to assist all of those in need. The Blood Service, whether intentionally or subconsciously, reinforced existing negative stereotypes about Africans, thereby impeding the willingness of these potential donors to give blood. While the participants accepted that there could be health reasons for donor deferral (e.g., being underweight, anaemic, and having recently been ill), and that there is a need to be vigilant with migrants from African regions because of potential higher levels of certain illnesses, there was consensus that more clarity and information about why deferral occurred should be communicated by the Blood Service staff: They [the Blood Service] should understand, I think, where we are coming from, understand us as human beings. Then I think the education, there is so much ignorance in the West about Africans. So, to help create a sort of common level, a playing field for everybody to understand them and they understand us, there should be education on both sides. Educate us about what is done here or what blood donation means and also they should be educated about us. (Man, 25þ, urban, migrant from Nigeria) There was strong emphasis that donations should be more appreciated. Respondents desired to be directly connected with

donors (see also Titmuss, 1971). For example, it was suggested by participants that donors should get letters of thanks from recipients, which might relate to the need to form a connection between donors and recipients. Respondents varied in whom they thought should provide recognition, but saw blood donation as a way to build inclusion and forge a relationship with the Blood Service, the recipient of their donation, and the wider community, which is consistent with the way the wider Australian donor cohort sees blood donation (see Alessandrini, 2005): They [the Blood Service] would welcome you because you are doing a good thing. (Woman, 25þ, urban, refugee from the Horn of Africa) It’s a communal feeling. You know, you watch some things on TV and when you see someone receive a transplant they show their appreciation, they thank people. The first thing in the mind of an African is community. If I’m right, would the average Australian appreciate receiving blood from an African? (Man, 25þ, urban, migrant from Nigeria) If they just contacted your parents or family or Church or something, and just say thank you, words that are coming from the heart. (Woman, 16e24, urban, refugee from Sierra Leone) There does appear to be a greater need for African migrants to have their donation acknowledged which, again, might relate to their community’s perceived meaning of blood. In Africa, donation is also often triggered by someone they know, that is, it is a direct replacement donation (Tagny et al., 2009). Not believing that a connection is being made, could result in less positive interpretations of experiences and would be exacerbated by any negative encounters while giving or trying to give blood. Implications and conclusions Findings from this study illustrate that the act of donating blood has a public health value e to ensure a safe, secure blood supply e and a social value e signifying feeling included, being an Australian citizen, having a sense of trust and security, and a sense of obligation and altruism to contribute towards the greater good - all findings which support earlier work in Australia (see Alessandrini, 2006; Robinson, Masser, White, Hyde, & Terry, 2008). However, there was dissonance between the public health value and the perceived social value of donating blood in this study. While the medical authorities wanted to source blood from African migrants to bolster stocks of rare blood types most frequently required by African communities, the study participants imagined their blood would go towards the general population (including white Australians) who would be unwilling recipients. A clear perception of marginalisation in public life and day-to-day interactions with the wider Australian community was apparent, which has also been found to occur more generally for African migrants (Australian Human Rights Commission, 2010; Correa-Velez et al., 2010). Unfortunately, some of the interactions did have racial undertones and experiences of physical and verbal abuse were reported by the migrants. Such encounters occurred in social and institutional settings and limited African migrants’ capacity and willingness to donate blood, as well as to participate in societal activities more generally. Even with these negative experiences, African migrants wanted to contribute and were positively disposed to donating blood. However, they did want to be recognised for making a contribution and felt a relational connection between donor and recipient was important, even though it was not facilitated in the Australian context and might not be practical. There was a strong feeling from the participants that the general community and health institutions believed Africans carried diseases like HIV/AIDS, and that migrants were contagious and

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diseased if they were from Africa. Many questioned whether their blood would be acceptable to the Caucasian population and often concluded otherwise, thus deciding not to donate. It is possibly even more worrying that some negative experiences reported were associated with dealings with health workers, who would be expected to focus on individual wellbeing rather than race. While not explicitly explored, such negative interactions could potentially be even more harmful in terms of social inclusion, as individuals are generally taught to have trust in the medical fraternity as a core social institution within society (Gilson, 2003). Of those who did donate, negative perceptions and experiences with the Blood Service deterred them from future donation. Work from the US, Israel, and France also shows that potential African and African-American donors felt as if their donation would not be valued because of their skin colour (see Grassineau et al., 2007; Merav & Lena, 2011; Shaz & Hillyer, 2010). For participants, having their donation recognised and appreciated was a powerful way to feel included and build social cohesion. Such findings echo earlier studies and show how donation is tied to national identity, citizenship and a sense of belonging (Copeman, 2009; Morgan et al., 2008; Simpson, 2009). To give one’s blood to the body politic is a literal way of becoming part of that political body. However, participants felt that their blood would be rejected, which compounded their sense of alienation, exclusion and foreignness. Unfortunately, exclusion was believed to be based on skin colour and extended to rejecting their blood and, therefore, denying their legitimate claims to social citizenship. While there have been recent efforts by the Australian government to enhance inclusion, we argue that the focus should shift from legislation to changing cultural norms and beliefs, that is, to have citizenry become accepting of all communities comprising the tapestry of Australian society. Laws, policies and guidelines already exist and all of the vignettes cited contravene the laws against discrimination in the workplace and community. The examples given of participant interactions with health-related professionals suggest that some of the professionals potentially displayed culturally-insensitive attitudes, which participants perceived as possibly racist. The experiences reported suggest that health professionals need to be aware that migrants could interpret experiences more negatively and differently from how they are intended, especially when they (i.e., the migrants) already believe they are marginalised by many in Australian society. There was, however, no suggestion that the negative views were institutionalised. The ARCBS and medical professions provide numerous staffing programs to integrate cultural sensitivity and social inclusion. In fact, when these results were brought to the attention of the ARCBS, further programs were instigated to address the issue to ensure that similar negative experiences did not occur in the future. Organisational training and remedial actions, however, also need employees to integrate social inclusion into their thinking and behaviour. Individuals who deviate from institutional policies or practices potentially risk migrants forming ongoing negative views of the overall institution. To counter the continued discrepancy between policy and practice in this area, political commitment and leadership are necessary alongside more inter-sectoral collaboration between government, the healthcare sector, private enterprise, universities, community and non-profit groups. The effort needs to be sociallydriven rather than legally enforcing inclusivity. Educating providers and communities about their rights and entitlements is necessary for marginalised groups to be able to self-advocate and leverage their capabilities to improve life outcomes. It is equally important to better communicate with the wider populace their responsibilities in terms of appropriate behaviour, thus minimising the causes of marginalisation in the first place.

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There also needs to be greater representation of migrant populations in popular discourse and media. If the Blood Service wishes to actively engage African migrants as blood donors it needs to have greater representation of Africans in their marketing campaigns. The Blood Service also needs to ensure that salient and relevant information about the African communities’ specific needs in relation to the blood donation are being delivered to those communities. Opportunities exist to explicitly tie social inclusion and blood donation through marketing campaigns e this would not only have positive flow-on effects in regard to inclusion but also position the Blood Service within a wider field of community capacity-building initiatives. As participants in this study intimated, there are several ways through which this could be done: greater representation of African migrants in marketing materials, cultural training of Blood Service staff, more clarity around the criteria to donate and the reasons for deferral, showing that the donation is appreciated, showing that their donations are necessary for their own community’s specific requirements, building relationships between donors and recipients, as well as stronger community engagement. While it may not be practical to send personalised thank you notes or even identify who gets blood from a given donor, developing ways that migrant donors can feel connected to the process and, thus, the recipients is also something that needs to be undertaken. Additional research is needed to determine the cultural applicability of any interventions that might then be applied to broader sets of migrant groups, as the findings identified in this study might not necessarily apply to other migrant communities. Nevertheless, a promotion campaign that fosters blood donation as something all members of the community need to do, it will also be salient for other minority and migrant communities. Furthermore, it is possible that, by using bilingual workers, some of the complexity of the responses may have been lost, or that the bilingual workers may have brought their own biases to their interpretations, even though every effort was made to ensure the rigour and reliability of the data, as outlined in our methods. Additional quantitative work is, therefore, necessary to complement this qualitative work to establish the generalisability of these findings. The impact of real and perceived discrimination on donation rates among African migrants is tied to their wider experiences of inclusion. Addressing this issue is challenging, not least because the responsibility for embracing migrant communities is dependent on the efforts of many different stakeholders and will take time to effect. However, there are significant potential gains, not just for African communities but also for the wider Australian society that make this a worthwhile task to pursue. Acknowledgements This project was funded by the Australian Red Cross Blood Service. We would like to acknowledge the Australian Red Cross Blood Service (the Blood Service), and the Australian governments that fully fund the Blood Service for the provision of blood products and services to the Australian community. We also gratefully acknowledge the technical advice and support of Mr. Neil Waters and Dr. Zoe McQuilten from the Australian Red Cross Blood Service, as well as the members of the African Review Panel, for their assistance with recruitment and community mobilisation. In addition, we would like to thank the African refugee and migrant communities for endorsing and participating in the study. References Alessandrini, M. (2005). Understanding Australian social capital and blood donation. Third Sector Review, 11(2), 35e58.

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