Attracting Hearts, Saving Lives: Advancing Healthcare Awareness through University-School Partnerships to Inspire a New Generation of Blood Donors (BDKQ)

1. Introduction

Blood donation is an altruistic and voluntary act that sustains healthcare systems worldwide by saving lives through transfusions (Wittock et al., 2021). Despite its critical role, shortages of safe and adequate blood persist in many countries (Haw et al., 2023). From 2008 to 2018, voluntary unpaid blood donations worldwide rose by 10.7 million units; however, fewer than 1% of the global population donates on a regular basis (WHO, 2021). The WHO recommends that at least 3% of the population should donate blood to ensure both safety (through haemovigilance programmes) and an adequate supply by blood group within health systems (Abdullah, 2022; WHO, 2021). Inadequate availability directly affects patients with chronic conditions, surgical needs, and those in emergencies, placing health systems under strain (Chand et al., 2023).

Donation rates are strongly influenced by national wealth and health infrastructures. In high-income countries, the rate stands at 31.5 donations per 1000 people, compared with only 5 in low-income countries (WHO, 2022). Income levels also affect plasma medicine production (Checkley et al., 2019), underscoring the need for policies that ensure equitable blood access across all socioeconomic contexts (Abdullah, 2022; Kaconco et al., 2023). Countries differ in their approaches, spanning legal and non-legal policy and practice for instance, to addressing matters pertaining to blood donation (Goncalez et al., 2008; Kaconco et al., 2023; Moreno et al., 2016). The decision to donate blood is strongly influenced by public awareness about donation, especially in countries where donation is voluntary (Bednall et al., 2013; Kumari & Raina, 2015). Conversely, a lack of knowledge about eligibility criteria, the blood donation process, and widespread misconceptions contributes to the global dearth of voluntary donors (Kumari & Raina, 2015; WHO, 2021). Individuals with limited knowledge about blood donation often assume they are ineligible to donate, which reinforces this misconception and reduces donor rates (Kumari & Raina, 2015). Recognising these factors underscores the importance of developing awareness interventions and globally reliable measurement scales to assess knowledge of blood donation, as increased knowledge, and, consequently, greater awareness is closely associated with higher donation rates (Zucoloto & Martinez, 2018; Zucoloto et al., 2020). It is therefore essential to design instruments that are appropriately tailored to this issue.

2. Method

Research Design

A quasi-experimental study was conducted to validate the BDKQ-Spain and to improve knowledge about blood donation through an educational intervention. The independent variable was the delivery of the educational intervention, and the dependent variable was the improvement of knowledge about blood donation. Other criterion variables included were gender, age, previous donation experience, educational level, university degree/master's degree, teacher's master's degree chosen and opinions.

Participants

The study sample consisted of 228 responses from individuals aged 17 to 51 years (M= 24.12, SD= 7.75), of whom 156 identified as female and 72 as male, see Table 1. The control group consisted of 62 students, 40 from the Nursing Degree (M= 23.08, SD= 7.02), 22 from the Occupational Therapy Degree (M= 22.29, SD= 4.66), of whom 45.16% were donors. The quasi-experimental group consisted of 166 responses, 61 from the Bachelor's degree (M= 17.05, SD= 0.20) and 105 from the Master's degree in Teaching (M= 29, SD= 7.31), of which 36.14% were donors. Regarding the quasi-experimental group, 36 participants from the Bachelor's degree group and 57 from the Master's degree in Teaching completed the pre-test prior to the intervention. However, during the interventions, 11 participants from the Bachelor's degree group and 12 from the Master's degree in Teaching did not attend. Consequently, only 25 Bachelor's students and 45 teacher training participants completed both the pre-test and post-test and took part in the intervention. In addition, three students from the Master's degree in Teaching joined the interventions, but only completed the post-test. Furthermore, Figure 1 has been added to illustrate the flow diagram of participant selection and the testing process. To evaluate potential attrition bias, we examined whether missingness at post-test was associated with baseline characteristics. First, gender distribution was compared by course and pretest/post-test status. Chi-square tests showed no significant differences in attrition by gender in either the high school group (χ² = 36, p = 0.42) or the Master of Teaching group (χ² = 45.24, p = .46). Age differences were assessed by course level at pretest and post-test. Independent-samples t-tests indicated no significant differences in age between completers and non-completers in the high school group (t = 0.27, p = 0.40) or the Master of Teaching group (t = 0.85, p = 0.40). Finally, pretest performance was compared between completers and non-completers within each course. ANOVA results showed no significant differences in pretest scores between completers and non-completers in either the high school group (F = 0.33, p = .90) or the Master of Teaching group (F = 0.30, p = 0.99). Overall, these findings indicate that attrition was likely missing at random and is unlikely to bias the study’s main comparisons.

A total of 228 responses to the questionnaire were obtained between the experimental and control groups. Inclusion criteria were established based on the selected educational levels and those participants who did not sign the informed consent form were excluded. See Table 1 for more sociodemographic data analysed in the study.

Instrument

A questionnaire was created via Microsoft Forms and mailed to participants and legal guardians containing informed consent and questions with personal and socio-demographic data, as well as a standardised scale (BDKQ24-Spain) and open-ended questions for additional comments.

The BDKQ-Brazil (Zucoloto & Martinez, 2018) assesses knowledge about blood donation through 24 items with three, four or five response options that address the requirements, process and frequently asked questions based on Brazilian blood donation regulations (Zucoloto et al., 2020). The calculation of the scores consists of a summation of the items after having assigned a value of 1 for correct answers and 0 for incorrect answers. The cut-off points established for knowledge about donation were 0-13 (low), 13-19 (medium) and 19-24 (high). The scores between the brackets are not exactly equal due to variation in the difficulty of the questions in the questionnaire. Higher scores on the BDKQ-Brazil indicate greater knowledge of blood donation (Zucoloto et al., 2020). In this study, a mean BDKQ24-Spain score of 14.88 (N=228, Min=2, Max=24 and SD=5.26) was obtained.

To establish content validity, the BDKQ24-Spain was adapted to Spanish through the translation and retranslation of the BDKQ- Brazil validated in Portuguese following the guidelines of the University of Michigan (2023). This process included a double translation carried out by experts in the field, as well as a piloting phase to ensure its adequacy and comprehension in the Spanish context. The questionnaire was further reviewed by Brotherhood of Blood Donors associations and by five experts in blood donation and education, three from Spain and two from Brazil, as well as through group sessions with high school and university students to evaluate comprehension and usability. As a result of this process, several modifications were made. Specifically, in items 5, 8, 10, and 16, the term “Brazil” was replaced with “Spain”. In addition, in items 3, 12 and 14, the Spanish Health System was added, and in item 20, millilitres were added to understand the measure of capacity of a cup to facilitate the answers. Therefore, following the validation process, the BDKQ-24, established through content validity, and the final BDKQ-22 Spain, obtained from the factorial analysis, are provided in the supplementary materials, which also include guidance on their use and interpretation.

Procedure and Intervention

After obtaining approval from the Ethics Committee. Prior to implementation, permission was first obtained from the school and university administration. Subsequently, the teachers then obtained consent from parents or legal guardians, and consent was also obtained from the students themselves, ensuring three levels of authorization. In the case of adult students, their individual informed consent was required. All procedures complied with institutional and national ethical standards, ensuring participant confidentiality and data protection throughout the study. The intervention was developed following PBL and SL methodologies and implemented in the Research Project subject in the Sixth Form over 80 hours of tutoring. In response to the needs identified by the participating educational centres, students, teachers, and university tutors collaborated with the Blood Donor Association and Brazilian experts to promote awareness of blood donation.

The educational programme used in this intervention was designed following the guidelines of the Spanish Brotherhood of Blood Donors (Blood drops that save lives), the Brazilian and Spanish Government's Donor Management Manual and the WHO. The contents of the intervention focused on highlighting the relevance of blood donation as a lifesaver, backed up by data on the need for donors. Requirements, including age, weight and health, were reported, and the procedure, quantity, time involved, and safety measures employed were detailed. Advantages for recipients and donors were discussed, as well as possible side effects, and advice was given on how to encourage donation in close circles and organise school campaigns, emphasising the responsibility of donating blood when coming of age. At the end, a gamification activity created by the researchers entitled "Donation Case Cards according to Personal Background" was developed, where groups of 4 participants chose suitable donors for fictitious patients.

The procedure followed during the intervention consisted of several stages. Firstly, all experimental groups completed the questionnaire (pretest) to assess prior knowledge and then the intervention was carried out with the Master's Degree in Teaching and High School groups. The intervention included presentations, gamification activities and lasted three sessions of 2 hours per session. At the end, the questionnaire (post-test) was applied to the experimental and control groups. The questionnaires were answered in the subjects of the participating teachers and lectures, through links sent to the institutional mail or posted on the platform of their subjects. In addition, the teachers and lectures communicated the results to the students during their classes, in order to increase knowledge about blood donation.

Data Analysis

The BDKQ-Spain was validated, and its factor structure was confirmed through both EFA and CFA (construct validity). This analysis was conducted using the JASP 0.16.4 X64 software. A promax oblique rotation was applied, and estimation was carried out through the Maximum Likelihood method (Marsh et al., 2020). For indices constructed from dichotomous (yes/no) scales, polychoric/tetrachoric correlations were employed to ensure appropriate validation. For dichotomous items (e.g., yes/no responses), reliability is best assessed using the Kuder–Richardson (KR) formula. KR-20 when item difficulty varies and KR-21 when items are assumed to have equal difficulty. A KR value above 0.70 indicates good reliability, as the formula is specifically designed for binary data and offers a more accurate estimate of internal consistency than Cronbach’s alpha (Alonso et al., 2025).

It is important to note the adequacy of the sample size for this analysis, since the number of responses was 10 times greater than the number of items (Marsh et al., 2020). Internal consistency was assessed through correlations, covariances, Cronbach's Alpha (α) of the deleted items and Omega de McDonald's (ω) of the deleted items. External and criterion validity were examined by relating sociodemographic variables to questionnaire scores (Field, 2018). The internal structure was first examined using EFA to explore the underlying dimensions, and the results were subsequently confirmed through CFA (Marsh et al., 2020). We established 0.30 as the minimum factor loading cutoff and selected items with higher loadings. These analyses are adequate to establish differences in the structure of the BDKQ and the identification of underlying scales. According to Putnick and Bornstein's (2016) criteria, invariance is considered adequate if the differences in ΔCFI are ≤ 0.01, ΔRMSEA are ≤ 0.015, and ΔSRMR are ≤ 0.015 The associations with background variables of the BDKQ-Spain will be determined by comparing it with the sociodemographic variables (Marsh et al., 2020). These analyses are suitable for establishing differences in the structure of the BDKQ-Spain and the identification of underlying scales.

In the study, descriptive and inferential analyses were conducted using IBM SPSS-27 to evaluate the intervention and further support construct validation. In order to address the main objective, Student's t-tests and ANOVA followed by Bonferroni's post hoc test were used to compare independent samples. In addition, Pearson's correlation was used to analyse relationships between BDKQ-Spain scores and age. A significance level of p < 0.05 was established (Field, 2018), and effect size was calculated using Cohen's d statistic, considering d = 0.20 (small), d = 0.50 (medium) and d = 0.80 (large). To calculate the effect size of the ANOVA test, the partial eta squared statistic (η_p²) was used, with η_p²= 0.01 (small), η_p²= 0.06 (medium) and η_p²= 0.14 (large). Correlations are considered small/medium/strong with r of 0.10/0.30/0.50, respectively.

3. Results

Reliability Analysis of BDKQ24-Spain

Table 2 shows the internal consistency of the BDKQ24-Spain, the means, the variances of its 24 items, the item-total correlation coefficients and the αs of the deleted item. The correlations between each item and the corrected scale score were mostly above 0.30, except for items 12, 14 and 22. In addition, item 22 was not significantly correlated with the total score. However, following the recommendations of Zyl and Klooster (2022) in the item selection process, items that differentiate extreme groups and whose α values are appropriate should not be removed, indicating that it was not necessary to remove any of these items (Marsh et al., 2020). In this study, the BDKQ24-Spain demonstrated good reliability, with a KR-20 coefficient of 0.85 and a KR-21 coefficient of 0.83. The mean questionnaire score was 14.88 (N = 228, Min = 2, Max = 24, SD = 5.26, σ² = 27.65). Finally, the BDKQ24-Spain also obtained high reliability (α = 0.87 and ω = 0.86) and a small inter-item correlation of 0.22.

Table 3 presents the difficulty and discrimination indices of the BDKQ24-Spain items in the study sample. Most items fell within the acceptable range for both difficulty and discrimination, which is considered optimal. However, items 3 and 12 were classified as easy and non-discriminatory, as they did not exceed the threshold of 0.26 (Alonso et al., 2025). It is therefore recommended that these items be removed from further analysis. Accordingly, they will not be included in subsequent factor analyses to evaluate their structural relevance.

EFA of BDKQ22-Spain

After analysing these data, the appropriateness of conducting a factor analysis (Marsh et al., 2020) was assessed and showed an adequate Kaiser, Meyer and Olkin test (KMO) value of 0.86 and a significant Bartlett's test of sphericity (χ2=17155.40, gl= 231, p <.001), indicating significant relationships between items and the appropriateness of conducting these factor analyses.

A EFA was performed by applying a promax oblique rotation, based on polychoric/tetrachoric correlations, and Maximum Likelihood estimation was used to maximize the probability of observing the given data (Ferrando et al., 2022). Following the AFE, two factors were identified in the factorial solution, see Table 4. The first factor explains 26.4% of the total variance and the second factor explains 21.8%.

The parallel analysis suggested that the two factors should be retained. All the items load above 0.40. The results of this study suggest that this structure should be tested through a CFA, comparing both one-factor and two-factor models.

4. Discussion

This study successfully achieved its objectives by developing and validating the Blood Donation Knowledge Questionnaire in Spanish (BDKQ-Spain), which exhibited strong reliability and validity. In addition, the educational intervention effectively increased knowledge about blood donation among high school students and future teachers. After the intervention, participants’ knowledge levels appeared broadly comparable to those of nursing students, indicating that active, contextually grounded educational programs may help reduce knowledge gaps across different educational groups.

The BDKQ22-Spain version, adapted from the BDKQ-Brazil (Zucoloto & Martínez, 2018), performed well psychometrically. In adapting the questionnaire, two items from the BDKQ-Brazil were removed because they were too easy and reflected principles already well known in Spain’s public health system. These items were the only ones referencing Spain, so their removal aids broader applicability in other Spanish-speaking countries. Their exclusion also helped avoid ceiling effects and improved the tool’s ability to discriminate between different levels of knowledge (Alonso et al., 2025). The EFA and CFA results aligned more closely with a two-factor model than with a unifactorial structure. These findings cannot be directly compared with those of the original study by Zucoloto and Martínez (2018), as they did not carry out factor analyses, although they did theoretically suggest that the scale functions best as a unidimensional measure. Given the modest indices reported, the existence of distinct subscales still requires further confirmation, and additional analyses are therefore recommended (Ferrando et al., 2022).

Our findings indicate that previous experience of blood donation was a strong predictor of higher knowledge, with 36.70% of participants having donated blood. This reflects a positive attitude towards altruistic behaviour, consistent with findings from other Spanish studies (Fernández de la Iglesia et al., 2020; Martínez-Santos et al., 2021, 2022). This altruistic mentality may have been reinforced by donation campaigns within the university environment, organised in collaboration with local associations such as the Brotherhood of Blood Donors, which also took part in this study. These campaigns enhance knowledge about blood donation, which primarily motivated participants to support the blood bank and help maintain its reserves (Chand et al., 2023; Haw et al., 2023; Martínez-Santos et al., 2021, 2022).

Nonetheless, several areas of limited knowledge linked to barriers to blood donation were also identified. These included fears of disease transmission, fear of needles and blood, concerns about possible negative health effects, as well as discomfort and weight-related issues, consistent with findings reported by Chand et al. (2023) and Haw et al. (2023). The persistence of these concerns within our sample is particularly striking given the high level of awareness of blood donation safety measures (with over 90% answering correctly). More concerning still is that fewer than half of participants correctly recognised that, under haemovigilance protocols, disease transmission through blood donation is unlikely within the Spanish health system, reflecting knowledge barriers described in other studies (Chand et al., 2023; Getie et al., 2021).

When compared to prior research, blood donation knowledge in our quasi-experimental pretest group was lower that reported in the original version validated by Zucoloto and Martinez (2018) among Brazilian health centre users, whose mean score was 15.35 (SD = 3.25, N = 1055). In our study, however, knowledge levels improved after the intervention, ultimately surpassing those of the Brazilian participants. Similarly, when compared with the study by Zucoloto et al. (2020), conducted among health science students (M= 13.67; SD = 7.96, N = 340, 81.50% female) of a comparable age and sample to ours, our pre-test scores across most groups indicated lower levels of blood donation knowledge. Post-test results, however, showed higher levels of knowledge than those reported by Zucoloto et al. (2020), with Occupational Therapy students in our study achieving mean scores comparable to those in their research. Consistent with previous research (Martínez-Santos et al., 2021, 2022), which suggests that nursing students have greater knowledge due to their involvement in different stages of the blood donation process. The research by Zucoloto et al. (2020) also indicated that health science students possessed the strongest background knowledge overall. However, it also showed that students of occupational therapy, nutrition, physiotherapy, and speech therapy had less knowledge than their peers in medicine and nursing, reflecting differences in the content covered within their respective disciplines.

As in the studies by Zucoloto and Martínez (2018) and Zucoloto et al. (2020), our study also identified demographic differences in blood donation knowledge, with women, older participants, and previous donors demonstrating higher knowledges. These differences in knowledge are attributed to several factors including accumulated experience over time, repeated exposure to the donation process, greater interest and awareness in sex-role-related health, culturally influenced prosocial behaviours, and greater accessibility to information and educational programmes (Abdullah et al., 2022; Chand et al., 2023; Checkley et al., 2019; Wittock et al., 2021). The relationship between these factors and willingness to donate may vary and be influenced by other sociocultural and individual factors (Zucoloto et al., 2020). Nevertheless, in line with our findings and previous research, the most notable factor appears to be the level of education received (Wittock et al., 2021; Zucoloto & Martínez, 2018).

Therefore, the present intervention has demonstrated that health education, applying active methodologies, is associated with the acquisition of knowledge about blood donation as these methodologies engage students, promoting deeper understanding and long-term learning, consistent with previous studies (Bray et al., 2023; Gil et al., 2021; Sáiz, et al., 2022). This positive outcome is also aligned with findings from other studies emphasising the benefits of integrating hands-on experiences, and discussions related to donation, which connect theory with practice, enhance intrinsic motivation to learn, and foster critical reflection (Fernández de la Iglesia et al., 2020; Getie et al., 2021).

Our study, consistent with previous research, underscores the importance of educating adolescents, future teachers, and health professionals about blood donation to foster awareness and a culture of solidarity from an early age (Zucoloto et al., 2020). Addressing donation among minors promotes altruistic values, encourages family involvement, and supports the development of a sustainable donor culture (Martínez-Santos et al., 2022). The participation of these groups in this research contributes to fostering a caring society that supports blood banks in maintaining an adequate supply of blood for those in need (Ackfeld et al., 2022; Martínez-Santos et al., 2021; Zucoloto et al., 2020). Moreover, as highlighted in this study and previous research, equipping health and education professionals with knowledge about blood donation is essential for patient safety, demystifying myths, recognising eligibility criteria, and managing potential complications (Martínez-Santos et al., 2021, 2022).

Strengths and Limitations

The strengths of the study are that the BDKQ22-Spain questionnaire demonstrated strong psychometric properties supported by reliable analyses, EFA and CFA, thereby confirming its validity and reliability for assessing blood donation knowledge in Spanish-speaking populations. BDKQ22-Spain provides a standardised tool for future evaluations. The intervention effectively enhanced knowledge about blood donation among high school students and future teachers. By incorporating innovative pedagogical approaches, such as SL and PBL, the study fostered active student engagement and meaningful, context-based learning in both secondary and higher education settings. Conducted in real educational settings, the research enhanced the practical relevance of its findings, while active methodologies supported the acquisition of practical knowledge about blood donation and encouraged informed health-related decision-making. Moreover, the quasi-experimental design, involving 228 responses from diverse educational and health-related backgrounds, provided a broad understanding of the intervention’s impact.

Despite the valuable findings obtained in this study, several limitations should be considered. The validation of the BDKQ-22 Spain did not include comparisons with other validated instruments, and the CFA indices supporting the two-subscale structure were modest. The two items removed during the EFA were specific to Spain, while the remaining items are broadly applicable across Spanish-speaking countries, nevertheless, it is recommended that the questionnaire be tested in other Spanish-speaking countries. The quasi-experimental design and sample diversity limited the ability to draw generalize findings broadly. Future research should carry out factor analysis in additional samples to confirm the structure of the questionnaire. It should also adopt more robust designs, including larger samples, and randomized cluster approaches to evaluate long-term effects and strengthen evidence. Additionally, expanding participant diversity across educational contexts would further enhance generalizability.

5. Conclusion And Implications

The objectives of this study have been successfully achieved, confirming the reliability, validity and relevance of the BDKQ22-Spain among high school students as well as educational and healthcare professionals. The educational intervention, conducted in collaboration with Brazilian and Spanish experts and the Brotherhood of Blood Donors, had a positive impact on participants, as evidenced by an increased in their knowledge about blood donation. High school students, prospective teachers, and Occupational Therapy students were found to have lower levels of knowledge compared with Nursing students. However, following the intervention, high school students and future teachers achieved knowledge levels comparable to those of Nursing students. These findings underscored the effectiveness of active learning methodologies and highlight the importance of Health Education in enhancing knowledge about blood donation within this population. The study also showed the value of partnerships between universities and schools in enhancing the quality of health education. Educational interventions of this kind are therefore essential for fostering awareness and knowledge of blood donation among high school students and future professionals in both health and education sectors.