Semen donor recruitment strategies a non-payment based approach

Transcription

1 Human Reproduction vol.12 no.10 pp , 1997 Semen donor recruitment strategies a non-payment based approach Ken R.Daniels 1 and Darel J.Hall Department of Social Work, University of Canterbury, Christchurch, New Zealand 1 To whom correspondence should be addressed Actual and projected prohibition of payment for semen donation in the UK and Canada has increased the need to examine alternative methods of donor recruitment. Evidence from a number of sources suggests that there is a large group of current and potential donors who are motivated more by meeting esteem needs than by payment. We develop an argument for using social marketing tools to create systematically an esteem-based approach to donor recruitment as an alternative to the payment approach. We conclude that esteem is a useful method of reciprocating the gift that donors make. Key words: donor insemination/payment/recruitment/semen donors/social marketing Introduction The Human Fertilisation and Embryology Authority (HFEA) in the UK has recently determined (HFEA, 1996) that payment for gamete donors is to be phased out. The HFEA has established a Working Group to recommend a timetable to implement its policy. In a similar move the Canadian Government has introduced to their Parliament a bill (Canadian Government, 1996) which will preclude the payment of any monies to gamete donors. The Canadian Bill goes further than the HFEA determination in that donors cannot be paid either a fee or expenses. It could be said that with such moves, the UK and Canada are catching up with France, where for 24 years there has been a policy of only recruiting unpaid donors (Lansac and Le Lannou, 1994). Given that payment has often been presented as a necessary incentive to the obtaining of semen donors (Golombok and Cook, 1994) there have been many concerns expressed (Canadian Fertility and Andrology Society, 1996; ReproMed Limited, 1996) that the availability of donors will decline and perhaps even cease, with the result that couples and individuals will not be able to receive donor insemination (DI) treatment. While the advent of intracytoplasmic sperm injection (ICSI) is likely to lead to a decrease in demand for DI, there is no doubt that there will be a continuing need for DI. Recruitment of semen donors has always been problematic (Editorial, 1979; Barratt, 1993; Cook and Golombok, 1995) and with the developments in the UK and Canada it seems likely that the problems will increase. Le Lannou and Lansac (1993), writing of the French situation, say that recruitment of donors is a major problem. However, they quote figures covering the period 1973 to 1988 in which they show that during this period a total of 7430 donors were recruited. Using a formula which takes account of the number of requests for DI, the maximum number of pregnancies per donor (five) and the selection rate of donors, they found that in 1989 it was necessary to recruit a minimum of 600 donors to meet the 3600 requests for DI. They state that in 1989 in fact 740 donors were enrolled. The French experience therefore suggests that non-payment does not necessarily lead to a cessation of supply. While the focus of this paper is semen donor recruitment, many of the issues raised can be generalized to oocyte donation. However, it is our belief that the recruitment of oocyte donors raises sufficient differences to warrant separate consideration. Consideration of the appropriateness of selling semen (Novaes, 1989; Daniels and Lewis, 1996), practice-based evidence of non-payment programmes of semen donor recruitment, particularly the CECOS experience in France (Lansac and Le Lannou, 1994) and the above policy changes, have led the authors to consider an alternative basis for recruiting men who will provide semen. The paper suggests that an esteembased recruitment model, drawing on marketing concepts as utilized in public health, should be debated as part of the evolving practice of DI. A future paper will outline specific strategies for implementing such a model. It is expected that the model and strategies will be piloted in three different countries with a view to testing their utility. Recruitment without monetary reward Semen donors have often been seen as the marginalized group in assisted reproduction equations not the patient, somewhat deviant because of their actions, and yet engaging in a necessary and important activity to achieve a desired outcome. They have in effect been a means to an end. With or without intent, the payment for semen has allowed the conceptualization of the donation process as a commercial transaction ended once the product, and cash, have changed hands (Novaes, 1989; Daniels and Lewis, 1996). Evidence from a number of studies suggests that the money is in fact a powerful motivating influence for some men, usually young, unmarried and often students (Cook and Golombok, 1995; Lui et al., 1995; Daniels et al., 1996a). However, these findings have emerged from studies that were recompense based, i.e. the respondents were recruited on the basis that they would be paid and it is to be expected that their views will reflect this European Society for Human Reproduction and Embryology

2 Semen donor recruitment It also appears that arguments could be made for a paymentbased system when the expansion of DI services required recruitment of larger numbers of donors. One of the groups for whom payment was attractive was students, including medical students, and of course, the latter were easily accessible. Students, in general, are also a group who have little discretionary spending power and therefore a small amount of money represents a relatively large increase in income. However, once cash ceases to be a significant motivator for people to donate, as is to happen in the UK and is proposed for Canada, the exchange process has to be re-conceptualized. Research into donor motivation provides a contrast between payment and non-payment systems of recruitment. In a recent paper (Daniels et al., 1996b) it was shown that men providing semen at two London clinics differed in a number of important ways. The paper describes the donors from the clinics, the first (A) where no payment was made, the second (B) where ten pounds was paid. Donors at clinic A were settled, at least moderately successful, had an above-average education, had a mean age of 40 years, had children, and were motivated more through altruism; donors at clinic B were unmarried, had no children, were highly educated (near and recent graduates predominated), and were motivated more by financial reward. It was suggested that the characteristics of the men differed essentially because of the different recruitment policies of the two clinics. It needs to be acknowledged that the numbers of men involved in the study were small and that as a result it is not possible to draw firm conclusions from the results. However, given that this is the first reported study seeking to compare the semen providers in two clinics who had different recruitment strategies the results point to important information that may be of assistance in the consideration of recruitment policies. In the paper by Daniels et al. (1996) the two clinics were referred to as clinic A and clinic B. On further consideration it also seems that the two groups of providers can be referred to as provider type A (type A) and provider type B (type B). The word providers is used to cover both those who received payment and those who did not, thus avoiding the reinforcement of the notion that those who are paid are in fact donors. In summary, type A providers reported they were motivated mainly by a desire to help often referred to as being altruistic, while monetary considerations were the major (but not only) self-reported factor for type B. That type B report altruistic motives alongside monetary motives has been reported earlier (Lui et al., 1995) and is consistent with the view that gifting (non-commercial activity, akin to altruism) in modern Western capitalist societies remains a central form of social transaction (Cheal, 1988). Other clinics have reported the recruitment of type A providers in New Zealand (Daniels, 1987; Purdie et al., 1994), Australia (Nicholas and Tyler, 1983; Daniels, 1989; Blood, 1992), and Sweden (Daniels et al., 1996c) (for a more in depth discussion see Daniels and Haimes, 1997). As reported by Purdie et al. (1994), a clinic in New Zealand targeted parents with young children as potential semen providers as they had established a social structure for their lives (Purdie et al., 1994). The targeted group can be characterized as type A. They had a settled notion of their life as indicated by being in a partnership that had a willingness to parent children. As with other type A providers they were of middle to upper socio-economic status, and they were of a similar age to the proto-type A of clinic A (Purdie et al., 1994: mean age 36 years, range 19 53; Daniels et al., 1996a: clinic A, mean age 40 years, range 31 51). There are also important parallels between the Purdie et al. (1994) group, Daniels et al. s (1996) clinic A and the French CECOS system (Lansac and Le Lannou, 1994). In France semen providers consist mainly of men in partnerships who have children. It appears that relative stability, shown in part by a long-term partnership and children, is an important predictor of donation, at least for type A men. It is reasonable to suggest that if a recruitment system is structured to attract men in partnerships, with children, then it should come as no surprise that those are the men who donate. The crucial point is that recruitment systems can be set up to attract donors who are not motivated by payment, just as they have been set up in the past to recruit those for whom monetary reward was the major consideration (Lui and Weaver, 1996). With the changes in the UK and the proposed changes in Canada, type B providers will not be attracted to programmes; if they are it will be in reduced numbers and only after modifying or changing their motivation for being involved. The choice facing clinics is to try to change or modify type B motivations, increase the number of type A men, or some combination of the two. There has been an assumption that type B men will only come forward if there is a monetary consideration for them, but it needs to be noted that this is based on the information gained from these men. They of course were recruited under a particular system and will be very influenced by this it is what they know. We perhaps need to rethink this assumption, and test the ideas out on those who are prospective providers, as suggested by Lui et al. (1995) and Shenfield and Steele (1997). The discipline of social marketing offers useful insights to analyse and reconstruct our assumptions and conceptual models. Applying social marketing to the recruitment of semen providers One of the leading marketing theorists, Professor Philip Kotler, describes marketing as human activity directed at satisfying needs and wants through exchange processes (Kotler, 1986). The implication is that means other than monetary reward exist to satisfy needs or wants of donors. Kotler further describes social marketing as a strategy for changing behaviour (Kotler and Roberto, 1989). The key difference is that marketing is more of a matching process, while social marketing includes the matching process but has more emphasis on normative behaviour modification. The goal of social marketing practice is to move a targeted population towards a desired behaviour. This is achieved through the best possible understanding of the desired population whose behaviour it is wished to modify. Both marketing 2331

3 K.R.Daniels and D.J.Hall and social marketing acknowledge that real behaviour change is difficult to achieve, hence there is an imperative towards understanding and using people s existing attitudes, beliefs and values to encourage the adoption of desired behaviours. The material that follows is based on knowledge drawn from the field of social marketing that is consistent with new approaches to public health and health promotion that places emphasis on the empowerment of individuals, families and communities to achieve well-being [see the Ottawa Charter for Health Promotion (WHO, 1986)]. Many of the policies and strategies from this field have been used in public health promotion and are therefore a part of the health system in general. On the other hand it does not seem as if this knowledge has been used in the field of semen donor recruitment, perhaps because it has not been seen to be necessary or appropriate. A model of non-payment-based gamete recruitment The basis of our non-payment-based gamete recruitment approach is the replacement of a money gamete transaction process by an esteem gamete transaction process. The discussion of marketing suggests that so long as esteem meets the needs or wants of a donor, then an ethical transaction, where all parties benefit, takes place. Abraham Maslow (1954) sought to explain individual motivation through a hierarchy of needs. In order of importance they are described as physiological needs, safety needs, social needs, esteem needs, and self-actualization needs. Our approach characterizes donation as satisfying esteem needs such as status, recognition, attention, importance and appreciation (Maslow, 1954). In a needs-based approach to motivation, money is a means to an end (Maslow, 1954). The needs to which money is applied by providers in payment-based recruitment systems have, to our knowledge, not been researched and any speculation we could offer would be of limited value. Groups or individuals who can give (or indeed take away) the donor s esteem are the donor himself, the donation recipient(s), clinic staff, the donor s family, the donor s friends, the donor s colleagues, and society as a whole represented by the esteem given by strangers. The use of known or personal donors (Purdie et al., 1994), along with changing patterns in relation to donor anonymity (Daniels and Taylor, 1993), suggest that in the future the offspring of the donor could also provide esteem. A useful working analogy is the blood donation system in New Zealand and other countries such as the UK and Australia. Blood donation in New Zealand can be described by the esteem that various groups give the donor. All the relevant groups associated with blood donation are likely to give esteem, in fact it is invited by the practice of giving donors a blood-drop-shaped sticker which bears the legend Be nice to me I gave blood today. Another sticker states Give life Give blood. A smile in the street from a stranger acknowledging one s donation is a sign of transmission of esteem as described by Maslow (1954), and at least anecdotally can be seen as a powerful motive. This process also acknow ledges and reinforces the social acceptability and value of the activity. The esteem-building process in blood donation contrasts with some of the practices that have been employed with semen donors. We are aware of clinics in which: donors were directed to a toilet to provide their semen, to a room that was locked from the outside or to a room that did not lock; interaction was with staff who were embarrassed and uncomfortable about receiving the semen, who treated the exchange in a very business-like manner, or who had no or little interaction with the provider. Offering esteem to prospective donors needs to be accompanied by an understanding of the influences on the prospective donor s decision to donate. The implication for the recruitment of gamete donors is that the recruiter must seek to understand the societal messages, including advertising and public relations, that are significant in the decision to donate, as well as the people that play an influential role. The use of advertising requires a great deal of thought and planning, some programmes being frustrated that their efforts to recruit via advertising (often involving professional public relations personnel) have brought few tangible results. The recruitment approach we describe has three strategy areas. The first concerns the prospective donors: understanding who they are and what they are like. The second concerns maximizing the benefits of donation to attract and retain donors, through an esteem-based approach. The third concerns understanding the influence of other people in the decision to donate. A comprehensive recruitment policy will focus on all these areas. It should be noted that the following strategies have been developed in relation to Western cultures and their applicability to other cultures needs further consideration. The prospective donors Blood donation provides a guide to the upper limit percentage of the population who might reasonably consider donation. Between 5 and 6% of the New Zealand population, for example, are blood donors. The numbers ceasing to donate are about the same as the number who are added to the donor register between 0.5 and 1% of the population, or people in the year to June 1996 (New Zealand Blood Transfusion Trust, 1996). One way of communicating with potential semen donors is to identify blood donors who are a reasonable fit to type A characteristics. Blood donors have been targeted by some DI programmes in the past, but we suggest in a rather passive way, e.g. displaying a poster. This is similar to some advertising which has the effect of the need being recognized, but does not lead to a response (Purdie et al., 1994). The steps to this could include a preliminary demographic screening, invitation focus groups from the group that demographically matched the required type, design of appropriate communication strategy. The communication strategy should consist of a mixture of advertising, public relations, promotions, personal contact (Kotler, 1986). The above exercise can also be undertaken with existing

4 Semen donor recruitment donors. The recruiter may find that this process, which of itself gives esteem, may engage providers thought to be motivated by money alone and encourage them to continue donating on a different basis. What becomes apparent with our emphasis is that recruiters must become engaged in a continuous dialogue with donors and identified groups that are potential donors to understand them better. At the same time this may have an effect of persuading some people to become donors during the process. The above process is potentially time-consuming and more expensive to establish. However, resource commitment should reduce to a minimum once effective systems have been put in place, as existing donors would be encouraged and are likely to play an active role in recruiting others whom they know. A recruiter with available resources, or who is forced to change, could seek to identify segments of the wider population that have a close fit to type A characteristics, and the social organizations they belong to, and commence communication with them. Census data in New Zealand, and no doubt in many countries, provides powerful demographic data. A partnership with a firm which targets customers with characteristics that show a close fit to the target market of the potential donor is the kind of example that could be considered. Recruitment outside the majority culture requires a specialized method best constructed in conjunction with the leaders of the minority culture targeted. Maximizing the benefits of donation through esteem Since esteem is the basis of our transaction model it requires a commitment to valuing donors themselves rather than just what they produce. Hence the clinic and its staff need to orientate thinking to that approach. One implication of this concerns the collection of semen. Some thought needs to be given to the space allocated for semen provision, also to the personal dynamics involved in handing over the container of semen: are the donors happier to hand the container over to a person or leave it in the room; is it an issue about who they hand the container to? Thought could be given to home collection by medical courier. There may be some advantage in encouraging partners to accompany donors as a recognition and affirmation of the partner s role(s) in the donation process. These considerations are based on discovering what current donors like and appreciate and building this into the system. Such an approach further conveys self-esteem in that it values the opinion of the participants. Costs to donors have to be known so that they can be balanced and exceeded by benefits that the gamete recruiter offers donors. The donor incurs costs that can include time, monetary, social support and psychological costs (Frederiksen et al., 1984), or, from a slightly different perspective, monetary, time, and perceived (psychological, social and physical) risks (Kotler and Roberto, 1989). The major explicit financial cost is travel. All other things being equal there is likely to be a negative relationship between travel costs and number of donors on low incomes. This may be an important consideration in contexts where desired ethnic minorities are more prevalent in lower income strata. Paying for travel expenses is different to paying for donation, especially considering that type B providers are usually single and that type A providers have partners and children to consider. One New Zealand donor with a young family and the heavy financial commitments that this entails said that:... some recompense for the rather lengthy trip to the none too centrally located National Women s Hospital would be greatly appreciated (New Zealand Department of Justice, 1985). Thus the desire not to disadvantage his partner and children seems to be the motivating factor for the desire for expense payment. The voluntary community work sector model offers a further reason for acknowledging the propriety of expense payment, at least in the New Zealand experience. Many organizations that rely on volunteer labour, for example the St John s Ambulance Service, pay volunteers a mileage allowance. The general position seems to be that volunteers should not be required to impoverish themselves while performing a service to the community, coupled with a pragmatic understanding of the economic situation of volunteers. Donation costs the donor his valuable time. One implication of this is that the recruiter must seek to minimize time spent on non-essential components of donation such as excessive form-filling or waiting. Physical risks, while real, are more easily quantifiable than psychological or social risks. However, it is likely, particularly with ova donation, that the perceived physical risks of the relatively uninformed are of a magnitude far greater than the actual physical risks. Hence the communication strategy must instil trust and confidence in the recruiter s message of the actual physical risks involved. The related area of new knowledge about physical wellbeing that a donor may receive has costs and benefits that need to be considered. A recruiter may find that a potential semen donor has a sexually transmitted disease or other illness. The reaction of the potential donor is difficult to predict, perhaps unhappy to have a disease while being grateful for its early discovery. However, our approach of esteem-building would, we argue, help to ameliorate the negative outcomes for the potential donors: our approach attempts to give esteem to those that even consider donation that is a worthy act itself whether it leads to donation or not. One Swedish clinic conducts a full medical check-up of the donor as part of its approach to recruitment, valuing the man as a whole person. The check-up also has clear benefits for the donor within the overall framework of the transaction. One of the psychological risks referred to in the literature is that of possible contact with offspring in the future (Lui et al., 1995: Cook and Golombok, 1995). The secrecy that has surrounded DI, and especially the identity of the donors, is beginning to change (Daniels and Taylor, 1993; Daniels and Lewis, 1996). The advent of parent groups of DI offspring advocating their rights to information, and of donors prepared to be identified, are all evidence of a changing culture. Available research in New Zealand (Daniels, 1987; Purdie et al., 1994 and earlier 1992), Australia (Kovacs et al., 1983; Rowland, 1984; Daniels, 1989; Blood, 1992), Sweden (Daniels et al., 1996c), the UK (Daniels et al., 1997), and one clinic in 2333

5 K.R.Daniels and D.J.Hall the USA (Mahlstedt and Probasco, 1991) suggests that those donors who are more open to possible contact in the future are again type A donors. Therefore, at least for these men, psychological risks may not be a major issue. The influencers on the donation decision process In terms of the initial decision to donate, some literature suggests that the female partner is important in the role in initiating the decision process, acting as a powerful influencing role on the potential donors attitudes, and may have the power of final decision or veto (Purdie et al., 1994). Regarding type A providers, we know these women are probably heterosexually inclined, have young children, and are at least middle class. A New Zealand study (Purdie et al., 1994) accessed couples through antenatal classes. Ways of communicating with women and men with the highest potential could be through schools, both of which have a large number of parent volunteers (which is itself a positive indicator that a person would at least be open to communication about donation). Groups that continue to be potential targets include husbands of obstetrics patients and men considering vasectomies. In France, 38% of donors during the period were recruited as a result of being referred by DI candidates (Le Lannou and Lansac, 1993). Semen from such donors is not used for the referring couples own treatment. This method of recruitment has obvious potential and also needs to be considered. In terms of esteem-building from the sources identified above, there are many possibilities. Esteem enhancement by people close to the donor would probably consist in part of giving those people information, and reinforcement for their involvement and assistance. There also seems to be a place for esteem for the donor s partner, and perhaps their offspring, recognizing their part in the process. For some this may mean sharing news of the birth of a child. At the wider social level, there seems to be a need to create a climate of acceptance of the diversity in the ways families are formed within the wider population. The use of mass media is a useful tool at raising awareness of diversity, the first step in acceptance. The use of this material by television programmes has a powerful impact on its normalization. Recruiters will be better served being pro-active in the mass media. A number of these strategies are likely to require a pooling of resources between competing recruiters. Jarillo and Stevenson (1991) identify two conditions for successful co-operation: the co-operation has to increase efficiency, and co-operation has to be achievable and sustainable. We suggest that the changes in the way recruitment may be undertaken provide a necessity for collective planning, at least in the initial phase of re-orientating to a non-payment-based recruitment system. The key to achieving and maintaining co-operation is trust (Jarillo and Stevenson, 1991). This is achieved when the expectations of the partners are that they will benefit in the long-term, therefore the importance of winning at each decision point becomes reduced. Again as recruiters move towards a new system a longer-term perspective should prevail Conclusion This paper has suggested that recent and proposed policy changes in the field of gamete donor recruitment in two countries require clinics to re-conceptualize the basis of their recruitment programmes. We suggest that a number of studies have shown that a desire to help infertile couples is a powerful motive and that this is related to what we have called esteem needs. This was summed up by one donor who said that donors need recognition and further that:... while blood donors receive recognition from the community in the form of being held in high regard and being granted time off work, there is no equivalent reward system for sperm donors (New Zealand Department of Justice, 1985). Several strategies are outlined based on a non-payment approach to recruitment: these are offered for discussion and debate. References Barratt, C.L.R. (1993) Donor recruitment, selection and screening. In Barratt, C.L.R. and Cooke, I.D. (eds), Donor Insemination. Cambridge University Press, Cambridge. Blood, J. (1992) Survey of Sperm Donor attitudes to the Central Register. Abstract of Presentation at the XIth Annual Scientific Meeting of the Fertility Society of Australia, Adelaide, December 2 5, Canadian Fertility and Andrology Society (1996) Response to Bill C-47: Human Reproductive and Genetic Technologies Act. A submission to the Canadian Government. 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