Blood safety considerations in the developing world—the problem of social desirability biases

S exually transmitted diseases are a global health issue that needs to be considered by health authorities to ensure blood safety. Blood safety is increased by optimizing blood donor screenings strategies before donation and applying the latest tests to identify diseases after donation. Importantly, predonation screening strategies help to identify potential risks related to window-period infections. A current EU project called TRANSPOSE (Transfusion and Transplantation: Protection and Selection of Donors; transposeproject.eu) studies European blood donor selection and donor protection policies and shows different screening strategies in use across Europe. The project aims to improve guiding principles and to provide guidelines for a standardized donor health questionnaire. The first descriptive findings from TRANSPOSE, reported in Amsterdam in 2019, indicated that some questions in a donor health questionnaire may be subject to social desirability biases, a type of bias in which a respondent tends to answer questions in a way that will be viewed favorably by others. Social desirability bias is especially problematic with screening questions about men having sex with men (MSM). Generally, social desirability biases as well as a lack of understanding of the meaning of questions in the donor health questionnaire is a substantial threat to the validity of the screening procedure. This threat is likely to be higher in societies with low levels of sex education and where donors may fear discrimination when answering the questions truthfully. Perceived social norms with respect to sexual behavior and, as a result, sexually transmitted diseases are a substantial barrier to ensure blood safety. In this issue of TRANSFUSION, the article by Zeng et al. finds substantive support that high-risk sexual behavior correlates with HIV infection among Chinese blood donors. The China Statistical Yearbook 2018 reports a disease incidence (1/100,000) of 4.15 for AIDS (ranked seventh) in China. Zeng et al. argue that despite the updated screening strategies by the Chinese authorities (including both serologic and nucleic acid test screening), the risk of HIV transmission by transfusion still persists. Additionally, Zheng reports that the Chinese political leadership substantially strengthened HIV prevention and treatment. However, the author also reports that the HIV incidence has increased to 4.15 in 2018 from a level of 0.23 in 2004, and that 92% of the new HIV diagnoses resulted from sexual transmission. The main reason for the increase in HIV transmission is attributed to MSM. Both Zeng et al. and Zheng argue that young Chinese have a substantial lack of HIV/AIDS knowledge and that safe sex practice education is underdeveloped. Specifically, Chinese from remote and undeveloped regions often fear social stigmatization and discrimination against homosexuals, despite the fact that homosexuality was decriminalized in 1997. In many developing countries, the authorities need to improve sexual education and reduce discrimination of MSM to reduce the HIV incidence and to increase blood safety. The more likely a society is to disagree with certain sexual behaviors, the less likely men will report MSM behavior in predonation screening procedures because they might fear legal or social consequences. We have observed a major research gap with respect to the validity of donor health questions related to MSM. As the social acceptance of MSM varies across countries and societies, we need new studies that address both the level of MSM and the causal impact of MSM on HIV. The susceptibility to social desirability bias may vary not only between individuals (e.g., different perceptions about social norms) but also within individuals (e.g., perceived sensitivity of different items). Furthermore, the social desirability bias may also stem from intrinsic motivations if MSM is personal to potential donors. Specifically, respondents may provide dishonest answers to prevent threats to their self-esteem or image and to maintain a positive self-concept toward both themselves and others. Thus, although donors typically value honesty and attempt to comply with their internal standards for it, they may underreport MSM within a certain range without negatively affecting their self-concept. Several methods to mitigate social desirability bias have been proposed in the literature. The most popular approaches involve using social desirability scales and the randomized response technique. Social desirability scales are often used as covariates in models, with the aim of purifying the measurement of the personality trait of interest (e.g.,MSM)by removing the variance that is associatedwith social desirability rather than the personality trait. However, these scales only represent a post hoc procedure to control for social desirability after data collection. Controlling for social desirability is particularly challenging when analyzing multidimensional constructs that are measured via multiple groups of items with varying degrees of sensitivity. We suggest that researchers can address this challenge using a combination of a randomized response approach for data collection and a multiscale item response theory model for data analysis. The basic idea of the randomized response approach is to provide confidentiality to donors by randomizing each response before it is observed doi:10.1111/trf.15687 © 2020 AABB TRANSFUSION 2020;60;225–226