Melián Alzola Martín Santana2020 - Article - ServiceQualityInBloodDonationS PDF

Service Business (2020) 14:101–129
https://doi.org/10.1007/s11628-019-00411-7
EMPIRICAL ARTICLE
Service quality in blood donation: satisfaction, trust

and loyalty
Lucía Melián‑Alzola1 · Josefa D. Martín‑Santana1
Received: 6 July 2019 / Accepted: 30 October 2019 / Published online: 20 November 2019
© Springer-Verlag GmbH Germany, part of Springer Nature 2019
Abstract
This study proposes and validates a service quality scale for the blood donation pro-
cess. It also analyses the impact that service quality has on donor satisfaction with
the donation process, the trust inspired by the blood transfusion centre and donor
loyalty in terms of repetition and recommendation. Based on a sample of 30,621
Spanish current blood donors, the proposed model was validated using SEM. The
results revealed how important the quality of the donation process is in achieving
donor satisfaction and reinforcing donor trust and loyalty.
Keywords Blood donation · Service quality · Satisfaction · Trust · Loyalty
1 Introduction
Blood is perceived as a very valuable resource to addressing healthcare needs and

guaranteeing the survival of human beings (Garraud and Tissot 2016). However,
for many reasons, the need for preserving optimal blood levels at blood banks is
becoming more and more pressing. Blood is perishable, so it has an expiration date
and there is a time limit for it to be used (Katsaliaki et al. 2014). On one hand, age-
ing populations and low birth rates reduce the number of potential donors. Moreo-
ver, medical innovation opens up possibilities (e.g. new types of transplants), which
diminishes blood reserves (Moog 2009). On the other hand, although there is a wide
range of motivation to donate (e.g. altruism, helping other people, self-image), the
donation process is perceived by the donor as being riddled with inconveniences and
apprehension, which can diminish their willingness to donate (e.g. fear of blood,
fear of needles or fear of contracting a disease, long distances to reach donation cen-
tres, inconvenient opening times, etc.) (Martín-Santana and Beerli-Palacio 2012;
Masser et al. 2013). In this context, blood banks must identify demand patterns and
* Josefa D. Martín‑Santana
josefa.martin@ulpgc.es
1
Universidad de Las Palmas de Gran Canaria, Campus de Tafira s/n,
35017 Las Palmas de Gran Canaria, Las Palmas, Spain
13
Vol.:(0123456789)
102 L. Melián‑Alzola, J. D. Martín‑Santana
storage capacity to schedule necessary donations at all times, so that basic needs are
satisfied (Güre et al. 2018).
Given the need to recruit and retain donors, research on the success of the dona-
tion process is an area of growing interest in the academic literature. This is shown
by works published in different fields, e.g. health services (Moog 2009), services
management (Boenigk and Helmig 2013), operations management (Güre et al.
2018) or quality management (Jain et al. 2015). However, blood donation as a ser-
vice still remains largely unexplored in the management literature. Nevertheless,
owing to particular characteristics of the area, research on blood donation is not
without difficulties. Thus, unlike the traditional market, where companies provide
a product or a service, in the field of blood donation it is the donor who offers the
product on a ‘not-for-profit’ basis. In this sense, blood donation is a non-exchange
context, where the product providers are the clients (the donors). They altruistically
(without economic remuneration) access a service (the blood donation centre). At
the centre, they usually perceive some risks (e.g. fear of needles, fear of blood, etc.)
or inconveniences (e.g. lack of time, long distances to reach transfusion centres,
etc.). These risks and inconveniences diminish the donors’ willingness to give other
people (usually strangers) something valuable to their own health, i.e. blood. This
changes the rules of the game. As a consequence, the literature has also focused on
the study of trust as a mechanism aimed at increasing donor loyalty (Chen and Ma
2015; Sundermann 2018). Thus, lack of trust could be a cause for the low repetition
rate among first-time donors.
Based on the above, this paper makes significant contributions to the literature.
Firstly, this study proposes and validates a scale to measure donation process qual-
ity, based on a sample made up of more than 30,000 donors. This will help iden-
tify the key aspects of donor experience success. Designing an optimal donation
experience for donors is essential to achieving donor repetition. With that in mind,
Carter et al. (2011) recommend incorporating the lessons learnt from client service
literature. This would allow centres to provide donors with excellent service and
improve the donation system’s productivity. In that regard, the study on the critical
factors for an optimal management of donor experience has a point of reference in
the SERVQUAL scale. This is proven by the works of Al-Zubaidi and Al-Asousi
(2012) and Saha and Bhattacharya (2019). Nevertheless, unlike other areas of aca-
demic literature, there is a significant gap in the design of ad hoc measurement
scales aimed at defining and evaluating the quality of donor experience from the
donor’s perspective.
Secondly, this research analyses how the quality of the donation process as a ser-
vice influences three donor-related result indicators (satisfaction, trust and loyalty).
These indicators have traditionally been analysed in the service literature, but in
other contexts and not always as a whole. Owing to the particular characteristics
of blood donation, this is a unique, interesting area of social research. Moreover,
this study is intended to contribute to an area of undue interest in social research,
to which the literature of services should give academic answers. Obviously, given
the need for donors to donate blood repeatedly (for which they must overcome their
fears and uncertainties), trust is included in the research model. This allows us to
determine how the quality of the donation process bolsters both donor satisfaction
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Service quality in blood donation: satisfaction, trust and… 103
and trust. It also enables us to study whether these two constructs increase donor
loyalty. Moreover, it can also serve as a basis upon which recommendations can be
made for donation centres on how to provide donors with a pleasant experience.
Thus, the system’s effectiveness and efficiency would be increased by consolidating
a pool of regular donors at a lower cost (e.g. already convinced donors, donors who
recruit other donors and designing donation campaigns with effective messages).
2 Theoretical background and hypotheses
2.1 Blood donation as a complex service: from recruitment to loyalty
The donation system has to recruit new donors and make them give blood repeat-
edly, turning them into regular donors (Al-Zubaidi and Al-Asousi 2012; Saha and
Bhattacharya 2019). Concerning donor recruitment, the responsible bodies must
convince the general public of the social importance of donation. This is not only
to preserve the system, but also to renew the current donor pool in a natural way.
However, efforts do not always translate into a higher number of recruited donors,
much less regular donors. If we factor in the fact that not all potential donors who
are willing to donate are able do it, success expectations are not always satisfactory
(Martín-Santana and Beerli-Palacio 2012). Thus, according to data of Bagot et al.
(2016), only 5% of ideal potential donors give blood, and only half of them do so
again. These data highlight how important it is that, after a potential donor has been
made to give blood, transfusion centres offer an optimal experience that improves
donor loyalty.
As a response to this problem there is a line of research that studies the anteced-
ents of donor retention. Bednall et al. (2013) identify six research programmes to
analyse the antecedents of blood donation behaviour and intentions: models based
on the theory of planned behaviour, analysis of prosocial motivations (altruism and
felt obligation) as possible drivers of donations, anticipated reactive emotions, eval-
uation of positive and negative experiences at donation centres, influence of donor
career stage and role of donor demographics. Firstly, the TPB establishes that inten-
tion is an antecedent of behaviour, where intention depends on attitudes (positive
or negative evaluations of engaging in some specific behaviour), subjective norms
(social pressure for engaging or not in some specific behaviour) and the individual’s
perceived control over an action (easiness or difficulty to carry out an action) (Ajzen
2011). In the context of blood donation, as pointed out by Bednall et al. (2013),
from the point of view of TPB, the decision to donate will depend on a positive
view of blood donation (attitude), the perceived social pressure for donation (subjec-
tive norm) and the beliefs that donation is under the individual’s perceived control
(perceived behavioural control). Thus, among the many studies that have applied the
TPB, Giles et al. (2004) confirmed the role of self-efficacy as a major determinant of
intention, as defined within the TPB in the context of blood donation. Masser et al.
(2013) applied a TPB approach to measure the intention to donate again among first-
time blood donors who experience a mild adverse event. However, as recognised
by Ajzen (2011), intentions can be poor predictors of behaviour. Consequently,
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different studies have adapted this model to adjust its predictive capacities (Masser
et al. 2008). Thus, Robinson et al. (2008) expanded the TPB in the context of blood
donation, incorporating factors such as anticipated regret and donation anxiety.
France et al. (2007) included antecedents of attitude related to previous experiences
(‘blood donation reactions inventory’ and ‘satisfaction’). In addition, the authors
added the personal moral norm in the act of donating as an antecedent of intention.
Moreover, Williams et al. (2019) empirically proved how appropriate it is to inte-
grate self-determination theory and the TPB to predict intention to donate blood.
In a model that links intention to effective behaviour, blood donation makes this
sort of research even more complicated. Given that the proportion of blood donors
is relatively low, we would need a large sample size to guarantee a sufficiently high
number of donors in order to get significant data (Holdershaw et al. 2011).
As for other research perspectives, the literature provides relevant evidence. With
regard to the analysis of prosocial motivations, Misje et al. (2005) confirmed that
altruism and empathy are key motivational factors for donation intention. Addition-
ally, Evans and Fergurson (2014) defined and measured blood donor altruism based
on three perspectives (biology, economics and psychology). Regarding the donor’s
emotional state as an area of research, Williams et al. (2019) analysed the emotional
psychology of blood donors in different stages of the donation process. Conner et al.
(2013) indicated that, together with other variables, anticipated negative and posi-
tive affective reactions are significant predictors of donation intention. As for studies
on donor experience, Martín-Santana and Beerli-Palacio (2013), and Gazibara et al.
(2015) empirically proved that donor experience is a determining factor influencing
donors’ intention to donate blood in the future. With regard to donors’ demographi-
cal characteristics, the influence of variables such as sex and age in the field of blood
donation has been widely analysed in the literature, as evidenced in the works by
Tscheulin and Lindenmeier (2005), Martín-Santana and Beerli-Palacio (2013), and
Charbonneau et al. (2016).
These studies on blood donation, in addition to providing different research
perspectives on the complexities of the act of donating, also help improve the
design of donation campaigns. The literature includes helpful data to adapt the
message to the target audience’s characteristics and increase the proportion of
donors. In this regard, Williams et al. (2019) suggested that identifying and under-
standing the donor’s emotional experience at different stages (before, during and
after donation) help design effective donor retention strategies. Martín-Santana
et al. (2018), in a study on donation campaigns advertised on the radio, suggested
adapting the message based on donors’ belonging to one of the three groups
identified according to their donation inhibitors. Eser et al. (2010) explained that
university students are good candidates for regular long-term donation and rec-
ommended creating a system of brief reminders to encourage donation. After
confirming that the more familiarised donors are with donation, the more will-
ing they are to donate, Martín-Santana and Beerli-Palacio (2013) suggested that
such donors should have a more active role in donation campaigns, sharing their
experiences and reducing donation-related fears that act as barriers to effec-
tive donation. Martin et al. (2019), who emphasised the influence of word-of-
mouth (WOM) on the behaviour of blood donors, suggested that donation centre
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managers should encourage donors to recommend others to donate. Moreover, the

authors believe that potential donors aged 18 to 30 are an interesting group to
target. Sundermann and Lepnitz (2019) empirically proved that a single mailing
approach is enough to motivate repetition in first-time donors, saving costs. In
addition, they indicated that the design and the message of mailings are more
important factors than frequency itself. Another very important line of research
recognised by Bednall et al. (2013) refers to the study of donation experience. As
indicated by Jaafar et al. (2017), who analysed positive and negative experiences
of donating, experience can encourage or discourage people from donating again.
As a consequence, optimal management of donation helps eliminate barriers and
promotes donation repetition, as well as incentivize people to recommend others
to donate. This is suggested in service literature which establishes that the com-
pany’s interaction with its clients is called ‘moment of truth’ or ‘service encoun-
ter’. As a result of this service encounter, the client assesses service quality and
creates a number of attitudes such as their degree of satisfaction and their future
behavioural intentions related to the organisation (Priporas et al. 2017).
In the donation chain, this ‘moment of truth’ corresponds to the donor’s experi-
ence with the act of donating. According to Craig et al. (2017), this process begins
when the donor arrives at the donation centre or service venue and fills in a ques-
tionnaire about life habits and clinical conditions. Next, the donor usually goes into
a waiting room and, after a few minutes, he or she is interviewed by the staff who
are qualified to assess his or her suitability as a donor. If the subject is accepted
as a donor, he or she goes into the waiting room again until it is his or her turn to
give blood. The donation process can last approximately 8–12 min. After that, the
donor goes out of the donation room into a recovery room. The donor is advised
to stay there for an average time of 15 min, although he or she is free to leave at all
times. This sequence in the donation process is similar to the Spanish procedure as
indicated in Royal Decree 1088/2005 which regulates the technical requisites and
minimum standards of blood donation and transfusion centres and services (Minis-
terio de Sanidad y Consumo 2005). Thus, the healthcare staff are required to inform
the potential donor of their rights and obligations. Before any blood extraction, the
donor must fill in a questionnaire and sign a confirmation that they have been told
about conditions that exclude them from donating. For instance, conditions such
as hepatitis, malaria or AIDS or practising unsafe sex are grounds for exclusion.
Additionally, the healthcare staff should draw up a medical history and examine
the donor at each donation to evaluate if they are in a suitable condition to donate.
These measures ensure that donation is not harmful for the donor and that it does
not have a negative impact for recipients. The evaluation of the donor’s suitability is
completed by assessing the results of their analyses. Kamel et al. (2006) discussed
and presented these issues when explaining the role of questionnaires for donors.
Given how important it is to provide the best donation experience, which both
addresses the requirements of the donation system and is satisfactory for donors,
this study analyses what factors of the process improve the quality perceived by the
donor and increase the donor’s satisfaction with the donation service. This would
influence his or her willingness to donate blood in the future.
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2.2 Donation process: measuring service quality
Measuring service quality is aimed at identifying the dimensions and attributes that
explain experience quality and customer satisfaction in different study areas. Sev-
eral proposals have been made on the multidimensional structure of service quality,
such as the SERVQUAL scale (Parasuraman et al. 1988). The SERVQUAL scale
has also been a point of reference as a measurement model to evaluate donation
experience. Al-Zubaidi and Al-Asousi (2012), who carried out a diagnostic analysis
to detect critical areas based on the experience of 354 donors, used the structure
of the original SERVQUAL scale, while also adapting it to the donation context:
tangibles (e.g. the centre’s staff are neat in appearance), reliability (e.g. the centre
performs the service correctly the first time), responsiveness (e.g. the centre’s staff
answers the donor’s questions diligently), assurance (e.g. the staff is qualified to
answer the donor’s questions), and empathy (e.g. the staff understands the donor’s
needs). Moreover, Saha and Bhattacharya (2019) followed a similar process (using
SERVQUAL adapted to the donation process), with some attributes written in a
negative sense. Some of the attributes that they analysed are as follows: tangibility
(e.g. the employees are well dressed), reliability (e.g. they are sympathetic and reas-
sure the donor), responsiveness (e.g. the service is quick), assurance (e.g. employees
inspire trust) and empathy (e.g. time schedules are convenient for donors). Another
interesting study was carried out by Jain et al. (2015). The authors measured service
quality of blood donation banks in India and the relative significance that donors
attribute to the analysed dimensions. Based on a version of the modified SERV-
QUAL scale, they contributed to the literature by validating their theoretical pro-
posal. The authors built a seven-dimension structure with its respective attributes:
processes (e.g. medical checks), tangibles (e.g. modern equipment), reliability (e.g.
the service is provided correctly the first time), responsiveness (e.g. promptness),
assurance (e.g. inspiring trust), empathy (e.g. service hours) and nonverbal com-
munication (e.g. professionalism). For their part, Veerus et al. (2017), who analysed
the donation experience of 453 donors in Estonia, suggested a theoretical scale that
was composed of several attributes created ad hoc. The scale, which was not vali-
dated, referred to matters related to staff (e.g. kindness and professionalism of the
staff), the process (e.g. waiting time at the reception) or the donor’s emotional state
(e.g. state of anxiety). Kokcu (2018) analysed the quality of the donation process
in a campaign at a military training centre. The author used a three-dimensional
theoretical scale with attributes related to the stages of the donation process: pre-
donation (e.g. the donor’s questions were answered), donation (e.g. the staff catered
for the donor at all times) and post-donation (e.g. recommendations made to the
donor). However, the study focused on clinical standards, but not from a service
management perspective. Moreover, the scale was not statistically validated. Finally,
Martín-Santana and Beerli-Palacio (2012) furthered this line of research. With a
sample of 712 Canary Island donors from the Red Transfusional Canaria (Canary
Island Blood Transfusion Network), the authors suggested and empirically validated
a quality scale for the donation process. The statistical analyses confirmed a scale
composed of four dimensions and thirteen attributes: personal attention (e.g. staff
training, a friendly, polite treatment), tangibles (e.g. cleanliness of the facilities and
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comfort), easy access (e.g. easy access to the donation centre, easy-to-find location)
and post-donation (e.g. the staff thanks donors after donation, usefulness of clinical
result information).
As a result of the above, it is concluded that the donation process quality must
evaluate the different stages of donor experience at the donation centre. It should
also assess a variety of issues, ranging from social and technical abilities to the
design and state of facilities. However, it is still a priority to consolidate the litera-
ture on donation process quality by designing and validating a measurement scale
for this service context. This will help close this gap in the literature.
2.3 Service quality and its result indicators in donors: satisfaction with donation

experience, trust in the centre and loyalty
2.3.1 Satisfaction with donation experience
Whereas quality is associated with service excellence or superiority, satisfaction is

defined as the consumer’s sense that consumption or experience provides outcomes
against a standard of pleasure versus displeasure (Oliver 1999). Along this line, Lee
et al. (2010) defined satisfaction as an assessment of service experience, either spe-
cific or global, influenced by service quality among other factors. A premise accepted
in the service literature is that service quality influences customer satisfaction posi-
tively (Parasuraman et al. 1988; Prakash 2019; Suhartanto et al. 2019). Accordingly,
a donor who perceives that the donation centre provides top quality service will be
more satisfied with the donation experience. On the other hand, a negative experi-
ence will lead to donor frustration and dissatisfaction, causing negative consequences
for the donation system. Thus, Veerus et al. (2017) pointed out that donation centres
should focus all their efforts on providing a donation experience that is as pleasant
as possible. Inspite of this, very few studies have addressed this relationship in blood
donation services, except those by Martín-Santana and Beerli-Palacio (2012), and
Fardin et al. (2018). These studies empirically demonstrated the positive influence of
service quality on donor satisfaction. Therefore, the following hypothesis is proposed:
H1 Service quality positively influences satisfaction with the donation experience.
2.3.2 Donor loyalty
Loyal donors are those who really ensure the balance of the donation system, so the
system’s ultimate objective should be to improve donor loyalty (Martín-Santana and
Beerli-Palacio 2012). To measure donor loyalty, two main approaches can be found
in the literature: behavioural loyalty and attitudinal loyalty. The former regards the
loyal customer as the person who buys the product or service frequently, whereas the
latter is based on forecasts, opinions, beliefs and future attitudes (Bandyopadhyay
and Martell 2007; Suhartanto et al. 2019). Since behavioural loyalty requires real
data about effective purchases or uses, a large number of studies choose to measure
attitudinal loyalty. Several studies measure loyalty using attributes such as ‘intention
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to repeat’ or ‘recommend the experience with the company to other people’ (Yoon
and Uysal 2005; Lai 2019). In the context of blood donation, Boenigk and Helmig
(2013) measure donor loyalty as a person’s willingness to donate again, to donate
more and to recommend relatives and friends to donate.
The literature supports the influence of service quality as an antecedent to loyalty. Pri-
poras et al. (2017) empirically proved, concerning the use of collaborative platforms, that
service quality improves customer loyalty. Parasuraman et al. (1988), when evaluating the
predictive validity of SERVQUAL, also empirically demonstrated how service quality
influences customer loyalty. Jiang et al. (2016) explain that quality dimensions positively
influence loyalty in the context of B2C e-commerce. In the context of blood donation,
Veerus et al. (2017) suggested that, if the donor has a poor experience when donating
for the first time, it becomes less likely that they will repeat the experience. Sargeant and
Woodliffe (2007) also confirmed the effect of service quality on the donor’s commitment
to the organisation and therefore donor loyalty. Despite the scarcity of studies in the con-
text of donation, the following hypothesis is proposed from an attitudinal perspective:
H2 Service quality positively influences the donor’s attitudinal loyalty.
Customer satisfaction also helps explain the customer’s loyalty to the organisa-
tion that provides the service (Hung et al. 2019; Suhartanto et al. 2019). Thus, Lee
(2017) empirically demonstrated the customer satisfaction-brand loyalty link on
loyalty programmes to members in the restaurant sector. Thus, in the field of vol-
untary work, Wisner et al. (2003) indicated that satisfied volunteers are more loyal
and, therefore, more willing to repeat and recommend other people to work volun-
tarily. In the context of blood donation, among the few studies that have been car-
ried out, Boenigk and Helmig (2013), Martín-Santana and Beerli-Palacio (2012),
and Nguyen et al. (2008) provide empirical evidence of the positive effect that donor
satisfaction has on the donor’s intention to give blood in the future. Therefore, the
following hypothesis is proposed:
H3 A satisfactory donation experience positively influences the donor’s attitudinal

loyalty.
2.3.3 Donor trust
Trust is the client’s confidence that the service provider will fulfil the donor’s
expectations by delivering what was promised explicitly and implicitly (Osman
and Sentosa 2013). As Kim et al. (2019) stated, organisations have begun to
encourage trust to achieve business goals and maintain competitiveness. In the
context of blood donation, trust is relative to the donor’s belief that their donating
of blood will have the desired effect (social good) because the donation system
will honour its responsibility, and that their actions will not have a harmful effect
on their health (individual risk) (Andaleeb and Basu 1995; Sargeant and Wood-
liffe 2007; Chen 2017; Sundermann 2018). For these reasons, trust is regarded
as an important factor in reducing some of the risks and uncertainty perceived
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by donors (Barrett et al. 2007). Recently, Chen (2017), who applies the extend
theory of planned behaviour to evaluate donation intention and behaviour, incor-
porates trust in blood donation agencies in their research model. Empirical data
suggest that trust in donation centres promotes a positive view towards donation.
Additionally, as pointed out in the commitment-trust theory (Morgan and Hunt
1994), trust has a positive influence on the intention to have a valuable, long-last-
ing relationship with another person or partner. From the above, we can deduce
that lack of trust should be studied as a factor to explain the low repetition rate
among first-time donors. Furthermore, lack of trust can also explain the unsatis-
factory repetition rates among donors in general terms.
The literature supports the proposal that service quality is an antecedent to cus-
tomer trust. As an evidence, we can cite the studies carried out by Eisingerich and Bell
(2008) and Osman and Sentosa (2013). These confirmed the positive influence that
service quality has on the customer’s trust in the organisation. In the donation context,
few works have empirically analysed the relationship between quality and trust. Nev-
ertheless, as suggested by Andaleeb and Basu (1995), the donation centre’s quality
standards help increase donor trust. Thus, clean facilities, friendly staff and a profes-
sional look, among other things, help secure the confidence of the donor. Despite the
scarcity of works in this regard, the following hypothesis is proposed in this study:
H4 Service quality positively influences trust in the organisation.
There is empirical evidence supporting the relation between donor satisfaction

and trust in the organisation, although said evidence comes from contexts that are
different from blood donation. Thus, Osman and Sentosa (2013) statistically proved
the influence that satisfaction has on customer trust in the field of rural tourism.
Likewise, Fernández-Sabiote and Román (2016) stated that satisfaction influences
trust in multichannel retail sectors. Moreira and Silva (2015), in a study on the trust-
commitment challenge in service quality-loyalty relationships, offered empirical evi-
dence that satisfaction is an antecedent of trust. Furthermore, Badri et al. (2015)
empirically proved the impact of customer satisfaction on trust in the organisation
in the field of public services. In the non-profit sector, Naskrent and Siebelt (2011)
proved how donor satisfaction influences trust in the organisation. With the object
of confirming this relationship in the blood donation sector, this study proposes the
following hypothesis:
H5 Donor satisfaction positively influences trust in the organisation.
Although service quality and donor satisfaction can have a positive effect in loyalty
towards the organisation, this might not be enough in the field of blood donation due to a
donor’s lack of trust in the donation centre. In the literature, there are several studies prov-
ing the influence of trust in customer loyalty (Correia Loureiro and Miranda González
2008). Thus, Sharma and Sharma (2019) pointed out that companies should strengthen
trust during the first stages of their relationship with the customer in order to ensure repeat
business. In this sense, Ranaweera and Prabhu (2003) established that satisfaction alone
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might not be enough to sustain long-term relationships, whereas trust can consolidate the
relationship by reducing the risk perceived in the service. Likewise, Forgas-Coll et al.
(2013) empirically demonstrated that trust positively influences on purchaser satisfaction
in the context of airlines website. Moreover, Aldas-Manzano et al. (2011) concluded that
trust plays an important role in situations that involve risk, such as blood donation. In this
context, Sundermann (2018) empirically proved the influence of trust on donor loyalty.
Given the need to confirm this relationship in the blood donation context, the following
hypothesis is proposed:
H6 Trust in the donation centre has a positive influence on attitudinal loyalty.
Figure 1 presents the model proposed in this study in graphical form. Causal rela-
tionships among the four constructs analysed in this study correspond to the formu-
lated hypotheses.
3 Methodology
3.1 Sampling
In this work, an online survey has been used as a data collection tool. The study
population consisted of current donors, i.e. men and women over 18 years of age
who live in Spain and have donated blood at least once in the last two years. In
Spain, blood donation is the responsibility of the so-called transfusion centres which
are ‘health centres where activities are carried out to collect and analyse human
blood or their components regardless of the purpose that they are used for, and to
treat, store and distribute them when they are used for transfusion’ (Ministerio de
Sanidad y Consumo 2005, p. 31292). In Spain there are 17 transfusion centres. Of
these, 14 centres collaborated in this study. These centres sent donors registered in
their databases an e-mail with the URL address of the online platform containing the
H1 SATISFACTION H3
H5
SERVICE H2 LOYALTY
QUALITY
H4 TRUST H6
Fig. 1 Proposed model
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questionnaire. The collaboration of public and private Spanish universities was also
requested. They distributed a message to the entire university community (teachers,
students, and management and service staff) through their institutional e-mail sys-
tems. Thus, recipients were invited to participate in the study by filling in the afore-
mentioned questionnaire. Moreover, both the donation centres and the universities
used their main social media accounts (mainly in Facebook and Twitter) and their
own platforms (e.g. official websites, newsletters, blogs) to disseminate the afore-
mentioned URL address. A brief message was also attached, encouraging people
to take part in the study. Although the number of participants was 36,459, the fact
that some questionnaires were not filled in completely reduced the final sample to
30,621 subjects. The questionnaire completion rate was 83.9%. Out of the final sam-
ple, 86.9% of subjects came from the blood transfusion centres’ databases.
The Spanish blood donors’ sociodemographic profile, as shown in Table 1, is
characterised as having both genders, with an even age distribution among the dif-
ferent considered intervals. It also presents a majority of subjects with university
studies (51.8%). Most donors work and have monthly income ranging from 1000 to
4000 euros (75.1%).
Table 1 Sample profile Characteristics N %
Gender
Male 14,464 47.2
Female 16,157 52.8
Age (years)
18–25 5440 17.8
26–35 6186 20.2
36–45 8337 27.2
> 45 10,658 34.8
Level of education
No education or primary 3786 12.4
Secondary 10,972 35.8
University 15,863 51.8
Working
Yes 23,752 77.6
No 6869 22.4
Total monthly income (€)
< 1000 4479 14.6
1001–2000 12,065 39.4
2001–4000 10,932 35.7
> 4000 3145 10.3
Total 30,621 100.0
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3.2 Measures
3.2.1 Service quality
Service quality was measured by means of a 19-item, 7-point Likert scale, in which
1 represented a ‘very negative assessment’; and 7, a ‘very positive assessment’. This
scale was intended to measure several aspects related to the donation centre where
the subject usually gives blood. Although the attributes collected in this scale are
based on a review of the literature (Martín-Santana and Beerli-Palacio 2012; Veerus
et al. 2017), a pre-test was carried out with collaborators from donation centres in
order to ensure the validity of its contents. The proposed scale initially consisted of
four dimensions: Tangibility (3 items), Accessibility (4 items), Personal Attention
and Professionalism (8 items) and Post-Donation (4 items). It can be affirmed that
this scale represents all the stages of the donation experience, as well as tangible and
intangible aspects of the process. Moreover, this scale has similarities (e.g. tangibil-
ity indicators and kindness of personnel) with other proposed scales in healthcare
services such as the HEATHCARE model (Lee 2017) and the quality dimensions as
suggested in Raposo et al. (2009).
3.2.2 Trust
Trust was measured with a 5-item, 7-point Likert scale, in which 1 meant ‘totally
disagree’; and 7, ‘totally agree’. The scale was designed according to the trust scales
developed by Sargeant et al. (2004), Sargeant et al. (2006) and Chen (2017) for non-
profit organisations.
3.2.3 Satisfaction
Satisfaction was measured with a 1-item, 7-point Likert scale, where 1 meant ‘com-
pletely dissatisfied’; and 7, ‘completely satisfied’, in order to evaluate donor satisfac-
tion with the donation centre. The works of Germain et al. (2007) and Morgeson
(2013) support using a single item to measure this construct. In the context of blood
donation, Martín-Santana and Beerli-Palacio (2012) used a single attribute to meas-
ure donor satisfaction.
3.2.4 Loyalty
Loyalty was measured through a 4-item, 7-point scale, where 1 meant ‘totally dis-
agree’; 7, ‘totally agree’. This scale was intended to measure the two dimensions
of loyalty: intention to repeat and intention to recommend. The future behavioural
intentions to repeat and recommend the service experience have been widely recog-
nised in the literature (Yoon and Uysal 2005; Boenigk and Helmig 2013; Lai 2019).
The content validity of the scales was pretested by ten collaborators of the trans-
fusion centres to guarantee their adjustment to the sector. In addition, before being
sent to the donor databases of the centres, the questionnaire was pretested by a
sample of 25 current donors to detect comprehension problems. After this double
13
Table 2 Definitive items of the scales
Constructs Code Items
Service quality
Tangibility (TANG) SQ1 The facilities provide privacy during the interview and the donation
SQ2 The facilities are sufficiently clean
SQ3 The facilities are cosy and comfortable
Accessibility (ACCE) SQ4 The donation centre or venue (either fixed or mobile) is accessible and easily avail-
able
SQ5 The donation centres or venues’ schedule is convenient
SQ6 Waiting time before blood collection is half an hour at most
SQ7 The duration of the donation process is convenient
Service quality in blood donation: satisfaction, trust and…
Personal Attention and Pro- SQ8 The staff perform well

fessionalism (PA&P)
SQ9 The staff always explain the requisites to donate, the donation procedure and give
recommendations for preventing potential negative effects after donation
SQ10 The staff are friendly and polite
SQ11 The staff look after my well-being at all times
SQ12 The staff inspire confidence during the donation
SQ13 The staff answer my questions accurately
SQ14 At the end of the donation, the staff showed their gratitude to me
Post-Donation (PD) SQ15 I get a thank-you letter or message after each donation
SQ16 The information sent from analysis results is useful
SQ17 The information that I am sent from analysis results is easy to understand
113
13
Table 2 (continued)
114
Constructs Code Items
13
Trust I trust that the donation centre or venue…
T1 always acts to guarantee an adequate blood supply
T2 acts ethically
T3 uses blood appropriately
T4 does not pressure donors
Loyalty
Intention (INT) L1 I am going to donate blood in the next four months
L2 I would like to become a regular blood donor (twice or more times a year)
Recommendation (RECOM) L3 I encourage my relatives, friends and co-workers to donate blood
L4 I discuss the positive aspects of blood donation among my relatives, friends and co-
workers
L. Melián‑Alzola, J. D. Martín‑Santana
process, the final questionnaire was published and was proceeded to its dissemina-
tion. Table 2 shows the final items in the scales and their dimensions after applying
the confirmatory factorial analyses.
Furthermore, according to some authors’ recommendations (Podsakoff et al.
2003; Reio 2010), the following procedures were used before collecting data to
minimise the likelihood of common method variance (CMV) bias: (1) anonymity
and confidentiality of the participants were ensured; (2) the questions measuring the
different constructs were separated in the questionnaire; (3) there was no introduc-
tion informing respondents about what the items were attempting to measure; (4) the
items were written clearly and precisely, avoiding complex wording and syntax as
well as double-barrelled questions or words with multiple meanings, so they are less
subject to bias; (5) the participants were told to give their honest appraisal of each
item and not a ‘preferred’ or ‘correct’ answer, thus avoiding the problem of social
desirability; (6) all answers required the same effort; and (7) clear instructions for
answering the questionnaire were provided at the beginning.
4 Analysis and results
This section was structured in two parts. Firstly, we described the analysis of the
validity of the different measurement scales used in this research to know its psy-
chometric properties. And secondly, we tested the proposed model using structural
equation models. Now, as a previous step, we analysed the existence of common
method variance to test for spurious internal consistency, which occurs when the
apparent correlation among indicators is due to their common source. With that
end, Harman’s single factor test was used, which is one of the most widely used
techniques to address the issue of CMV. We tested for this by jointly including the
thirty items of the different scales to detect the existence of a single or various fac-
tors, one of which would explain most of the total variance. Six factors emerged
explaining 65.69% of the variance. However, the first factor only explained 33.99%,
while the remaining factors explained 31.70% of the variance. Accordingly, com-
mon method variance does not appear to be a problem in this study, since no method
factor emerged.
4.1 Analysis of the validity of the measurement scales
4.1.1 Validation of the scale of service quality
The validation process of this scale began with an exploratory factor analysis with
varimax rotation. This was done with the aim of identifying their dimensions, given
that it is an ad hoc scale designed for service quality in blood donation. The results
explain an appropriate proportion of the total variance (64.39%). They also point to
the existence of four dimensions which correspond to those previously established
when designing the scale (Tangibility, Accessibility, Personal Attention and Profes-
sionalism, and Post-Donation). However, the results suggest streamlining the scale
13
Table 3 Confirmatory factor analysis of service quality

Causal relationships Standardised t p Internal consistency
estimators
Fit measures: χ2(115) = 12,762.500, p = 0.000, CFI = 0.957, NFI = 0.957, RMSEA = 0.060

TANG ← service quality 0.774 CR = 0.798
ACCE ← service quality 0.896 77.716 0.000 AVE = 0.515
α = 0.873
PA&P ← service quality 0.715 80.445 0.000
PD ← service quality 0.382 53.062 0.000
SQ1 ← TANG 0.685 124.568 0.000 CR = 0.828

SQ2 ← TANG 0.787 144.448 0.000 AVE = 0.618
α = 0.772
SQ3 ← TANG 0.875
SQ4 ← ACCE 0.549 76.526 0.000 CR = 0.725

SQ5 ← ACCE 0.636 85.464 0.000 AVE = 0.399
α = 0.696
SQ6 ← ACCE 0.623
SQ7 ← ACCE 0.708 91.522 0.000
SQ8 ← PA&P 0.773 124.136 0.000 CR = 0.931

SQ9 ← PA&P 0.687 111.562 0.000 AVE = 0.660
α = 0.917
SQ10 ← PA&P 0.870 137.596 0.000
SQ11 ← PA&P 0.894 140.747 0.000
SQ12 ← PA&P 0.905 142.199 0.000
SQ13 ← PA&P 0.847 134.382 0.000
SQ14 ← PA&P 0.675
SQ15 ← PD 0.541 96.181 0.000 CR = 0.828

SQ16 ← PD 0.881 143.377 0.000 AVE = 0.626
α = 0.802
SQ17 ← PD 0.900
by eliminating two items of the initial scale, with communalities and factorial loads
lower than 0.5, and by moving one of the items to another dimension. Based on
these results, a second-order confirmatory factorial analysis (CFA) was applied. The
results of the analysis are collected in Table 3. They showed that the indicators of
global fit were within the values recommended by the literature. Therefore, we can
conclude that the specified model adequately reproduces the observed covariance
matrix. This measurement model showed a suitable fit, since the values of CFI were
higher than 0.95 and the values of RMSEA did not exceed the recommended maxi-
mum of 0.08. The model demonstrated acceptable levels of individual reliability,
since the relationship between each item and its respective dimension/construct was
statistically significant. Standardised regression weights were higher than or very
close to 0.7, and t statistic values were also
significant. The measurements of inter-
nal consistency had very satisfactory levels. So, the values ofcomposite reliabil-
ity (CR) were higher than 0.70 and the extracted variances (AVE) exceeded 0.50,
13
Table 4 Confirmatory factor analysis of trust and loyalty

Causal relationships Standardised t p Internal consistency
estimators
Fit measures: χ2(17) = 471.552, p = 0.000, CFI = 0.997, NFI = 0.996, RMSEA = 0.028

INT ← LOYALTY 0.743 CR = 0.578
RECOM ← LOYALTY 0.524 28.862 0.000 AVE = 0.413
α = 0.667
L1 ← INT 0.521 CR = 0.597

L2 ← INT 0.773 42.635 0.000 AVE = 0.434
α = 0.553
L3 ← RECOM 0.857 CR = 0.853

L4 ← RECOM 0.867 74.019 0.000 AVE = 0.743
α = 0.852
T1 ← TRUST 0.869 CR = 0.896

T2 ← TRUST 0.926 222.033 0.000 AVE = 0.688
α = 0.887
T3 ← TRUST 0.863 199.950 0.000
T4 ← TRUST 0.627 122.161 0.000
except for the Accessibility dimension. The Cronbach’s alpha values corroborated

those obtained in the composite reliability. These results indicated that the measure-
ment model of the service quality can be considered as valid.
4.1.2 Validation of the scales of trust and loyalty
The reduced number of items intended to measure loyalty as a second-order model

have forced us to validate loyalty and trust constructs jointly, in order to achieve
the model specification (see Table 4). In this case, the results showed that the
model, in spite of being statistically significant, presented very satisfactory val-
ues for other indicators of global fit ( CFI = 0.997, NFI = 0.996, RMSEA = 0.028).
Therefore, we can conclude that the specified model adequately reproduced the
observed covariance matrix. The model showed a satisfactory individual reliabil-
ity, since the relationship between each item and the construct was statistically
significant. Standardised regression weights were greater or closer to 0.7 and t
statistic values were also significant. As for the measurements of internal con-
sistency, the indicator value of CR exceeded 0.70, and it was higher than 0.50
for AVE, except for the Intention dimension. The value of Cronbach’s alpha
corroborated that obtained in the composite reliability. These results therefore
indicated that the scale of trust can be considered valid. Regarding Loyalty, the
results advise the inclusion of additional items to improve its reliability. In spite
of this fact, this construct was kept in the model because loyalty is one of the
13
Table 5 Evaluation of the Constructs Mean (SD) 1 2 3 4

discriminant validity
Service quality (1) 6.11 (0.73) 0.718
Trust (2) 6.56 (0.73) 0.518 0.829
Satisfaction (3)a 6.62 (0.76) 0.481 0.402 –
Loyalty (4) 6.22 (0.92) 0.284 0.309 0.289 0.760
a
Satisfaction scale consists of 1 item
most important performance variables in blood donation. Blood transfusion cen-

tres design loyalty programmes. Therefore, this work could be useful to describe
the antecedents of loyalty, and this could help in decision-making.
Meanwhile, the discriminant validity of the four constructs was tested for.
To carry out this validation, we created a new variable for each construct. We
did this through a weighted average of the scores that the respondents gave to
the items/dimensions that make up each dimension/construct weighted by each
of their regression weights in the previous CFA. There is discriminant validity
if the correlations between the constructs are lower than the square root of the
AVE of each one. Table 5 shows the results of the analyses undertaken to this
end. It can be seen that the square roots of all the AVEs are greater than the ele-
ments not on the diagonal. Therefore, it can be affirmed that the scales also pos-
sess discriminant validity. The average values collected in this table indicated
that current blood donors throughout the country perceived a high level of quality
(M = 6.11), were very satisfied (M = 6.62), trusted the centres where they gave
blood (M = 6.56) and showed high loyalty (M = 6.22).
4.1.3 Descriptive analysis of service quality
The relevance of this study motivates a descriptive analysis of the attributes included
in the scale and its dimensions. Table 6 shows the results of this analysis, also includ-
ing the proportion of donors who have assigned the maximum score of 7 points to
each quality attribute. This indicates the scope of excellence in the management of
the donation process. The results suggested that (1) global service quality perceived
by donors was satisfactory (MService Quality = 6.11), highlighting Personal Attention
and Professionalism (MPA&P = 6.60) and Accessibility (MACCE = 6.01) as strengths,
and attributes related to Post-Donation (MPD = 5.73) and Tangibility (MTANG = 5.96)
as areas of improvement; (2) there is margin for improvement in all quality dimen-
sions, although it is much smaller in the dimension related to Personal Attention and
Professionalism, since most standard deviations of its attributes are not greater than
1, and the percentage of excellence is greater than 60% in all cases; (3) in the Tangi-
bility dimension, the attribute that deserves special attention is SQ1, related to pri-
vacy at facilities, with a lower score and a greater deviation (M = 5.36, SD = 1.56),
as well as a percentage of excellence of only 30.9%; (4) in the Accessibility dimen-
sion, two attributes can be improved, concerning schedule flexibility at donation
centres and waiting times before blood collection (SQ5 and SQ6), and in both cases
13
Table 6 Descriptive analysis of service quality
Attributes/dimensions Code Items Mean SD % (score = 7)
Tangibility (TANG) SQ1 The facilities provide privacy during the interview and the donation 5.36 1.56 30.9
SQ2 The facilities are sufficiently clean 6.41 0.92 60.8
SQ3 The facilities are cosy and comfortable 6.03 1.15 45.2
Accessibility (ACCE) SQ4 The donation centre or venue (either fixed or mobile) is accessible and easily available 6.29 1.07 58.0
SQ5 The donation centres or venues’ schedule is convenient 5.81 1.40 42.2
SQ6 Waiting time before blood collection is half an hour at most 5.57 1.55 37.5
SQ7 The duration of the donation process is convenient 6.37 0.98 59.9
Personal Attention and Professionalism (PA&P) SQ8 The staff perform well 6.63 0.71 72.0
SQ9 The staff always explain the requisites to donate, the donation procedure and give 6.52 0.91 69.9
recommendations for preventing potential negative effects after donation
Service quality in blood donation: satisfaction, trust and…
SQ10 The staff are friendly and polite 6.66 0.71 74.9
SQ11 The staff look after my well-being at all times 6.69 0.68 77.0
SQ12 The staff inspire confidence during the donation 6.66 0.70 75.0
SQ13 The staff answer my questions accurately 6.63 0.74 72.7
SQ14 At the end of the donation, the staff showed their gratitude to me 6.34 1.07 62.1
Post-Donation (PD) SQ15 I get a thank-you letter or message after each donation 5.56 1.89 48.7
SQ16 The information sent from analysis results is useful 5.77 1.72 51.0
SQ17 The information that I am sent from analysis results is easy to understand 5.80 1.72 51.8
Tangibility (TANG) 5.96 1.03 –
Accessibility (ACCE) 6.01 0.93 –
Personal Attention and Professionalism (PA&P) 6.60 0.65 –
Post-Donation (PD) 5.73 1.52 –
119
13
Service quality 6.11 0.73 –
R2 = 0.348
Tangibility
0.590*** SATISFACTION 0.200***
Intention
0.727***
0.053*** 0.778***
Accessibility
0.840***
SERVICE 0.212*** LOYALTY
QUALITY
Personal 0.793***
Attention and 0.509***
R2 = 0.309
Professionalism
0.402***
Recommendation
0.604*** TRUST 0.254***
Post-Donation
R2 = 0.405
***p < 0.01 GOODNESS OF FIT
Χ 2(288)= 17667.915 ( p=0.000), CFI = 0.960, NFI = 0.960, RMSEA = 0.044
Fig. 2 Results of the proposed model
deviations are greater than 1, and the percentage of excellence is lower than 45%; (5)
in the Personal Attention and Professionalism dimension, the results are quite satis-
factory, although there is a greater deviation and a lower percentage of excellence in
the attribute related to the gratitude shown by the staff to the donor at the end of the
collection process (SD = 1.07 and % = 62.1); and (6) in the Post-Donation dimen-
sion, the margin for improvement is greater, since mean values of all attributes are
not greater than 6, deviations are larger (ranging from 1.72 to 1.89), and percentages
of excellence registered are not greater than or are very close to 50%.
4.2 Hypotheses testing
To test the causal model, structural equation modelling (SEM) was applied, using the
variance–covariance matrix as input data and based on the maximum likelihood esti-
mation method (MLM). The results of the proposed model showed good goodness-
of-fit [χ2(288) = 17,667.915, p = 0.009; CFI = 0.960; NFI = 0.960, RMSEA = 0.044],
since the CFI value was higher than 0.95, and the RMSEA value was lower than
0.08 (Mathieu and Taylor 2006). These results, shown in Fig. 2, demonstrated that
(1) Service Quality is a direct antecedent of Satisfaction (β = 0.590, p = 0.000), Trust
(β = 0.604, p = 0.000) and Loyalty (β = 0.212, p = 0.000), thus supporting H1, H4
and H2; (2) satisfaction is a direct antecedent of Trust (β = 0.053, p = 0.000) and
Loyalty (β = 0.200, p = 0.000) thus supporting H5 and H3; (3) trust is a direct ante-
cedent of Loyalty (β = 0.254, p = 0.000), thus supporting H6; and (4) the proposed
model explains 34.8% of Satisfaction, 40.5% of Trust and 30.9% of Loyalty.
The importance of generational replacement in blood donation justifies the need
to assess if donors’ assessments are influenced by age. For this reason, que after con-
trasting the hypothesis, it was deemed appropriate to carry out an one-way ANOVA,
as well as Tukey statistical tests, to find out whether there were differences between
the average values of the analysed constructs (service quality, trust, satisfaction and
13
Table 7 Differences in average values according to donor age

Constructs Total 18–25 26–35 36–45 > 45 F Tukey
(1) (2) (3) (4) (p) (p < 0.01)
Service 6.11 6.01 6.06 6.11 6.20 97.889 1–2

quality (0.73) (0.74) (0.74) (0.74) (0.70) (0.000) 1–3
1–4
2–3
2–4
3–4
Trust 6.56 6.53 6.54 6.55 6.60 18.405 1–4

(0.73) (0.72) (0.75) (0.74) (0.70) (0.000) 2–4
3–4
Satisfaction 6.62 6.48 6.57 6.64 6.70 107.891 1–2

(0.76) (0.88) (0.79) (0.71) (0.69) (0.000) 1–3
1–4
2–3
2–4
3–4
Loyalty 6.22 6.27 6.27 6.19 6.19 16.753 1–3

(0.92) (0.88) (0.90) (0.92) (0.94) (0.000) 1–4
2–3
2–4
loyalty) and donor age. Table 7 shows that differences can be found among all con-
structs among the four age groups. For all constructs, it can be observed that the
older the donor, the higher the reported values. The greatest differences were found
for service quality and satisfaction (F = 97.889 and F = 107.891 respectively).
5 Discussion
In most countries, blood donation is voluntary and the donor does not get any
monetary compensation. For this reason, blood banks should develop strategies
to recruit donors who are willing to visit transfusion centres or blood collection
mobile units selflessly. The altruistic nature of blood donation can be understood,
as indicated by Garraud and Tissot (2016), because blood is a very important pub-
lic resource to meet health needs and ensure human survival. Moreover, blood can-
not be produced artificially, so it is a scarce and valuable resource. The proportion
of valid donors who decide to donate is low with regard to the potential donor pop-
ulation. Therefore, it is necessary to design the optimal donation process to maxim-
ise perceived quality, satisfaction, trust in the donation centre and loyalty. By this
means, not only are social objectives of the utmost importance met, e.g. ensuring
that the health system works, but also lower investments are required for campaigns
13
aimed at recruiting new donors and retaining current donors. The main conclusions
and theoretical and practical contributions of this work are presented in the follow-
ing paragraphs.
5.1 Theoretical implications
Given the role of donation process quality in achieving the donation system’s effec-
tiveness and efficiency, it is justified to design and validate a quality measurement
scale that is adapted to the blood donation context, as intended in this study. Boenigk
et al. (2011) support this implication. The authors stated that blood donation ser-
vices should focus on optimising the design of the donation experience in order to
recruit and retain donors. Thus, if a donor has a bad experience when donating due
to physical causes (nausea, weakness, etc.) (Masser et al. 2013) or poor service man-
agement (excessive waiting times to donate, unclean facilities, etc.) (Saha and Bhat-
tacharya 2019) it will diminish donor loyalty. However, few academic studies define
the dimensional structure of donation process quality. Based on a review of the liter-
ature and meetings with industry experts, this work has proposed a theoretical scale
of donation process quality consisting of four dimensions (tangibility, accessibility,
personnel and post-donation) and fourteen attributes. With a sample of more than
30,000 Spanish donors, this work empirically validates the proposed scale. Thus, it
will serve as a point of reference both for future academic studies and for transfusion
centres when planning, controlling and improving quality. According to the Tangi-
bility dimension (recognised in SERVQUAL), facilities should be comfortable and
clean, and the donor’s privacy should also be guaranteed. The Accessibility dimen-
sion essentially assesses the donor’s time schedule, e.g. waiting times and time
needed to reach the donation point. This dimension, which is close to the Empathy
dimension of the SERVQUAL scale, is intended to reduce transaction costs for the
donor. The staff-related dimension is a hybrid of the Reliability, Responsiveness and
Security dimensions. It illustrates how suitable the staff are to perform their jobs in
an efficient, effective way. The Post-Donation dimension seeks an immediate result
for the service encounter in the thanking of donors for their efforts and compensat-
ing them, e.g. with useful blood analyses. For this reason, attributes such as the Reli-
ability and Empathy dimensions of SERVQUAL are incorporated.
The analysis data confirmed the impact of service quality on donor satisfaction,
as well as the effect of these two constructs on donor loyalty. Thus, the study con-
firmed the ‘moment of truth’, as it is called in the service literature (Bitner et al.
1994). Each donation act can contribute in a positive or negative way on donor
loyalty depending on the centre’s management. Especially in scenarios where the
donation act is altruistic and depends on the subject’s willingness, each scheduled
service or donation encounter can diminish the value of all the previously made
efforts. On the other hand, the donation experience is the organisation’s chance to
contribute to donor’s trust, reducing the donor’s fears. As pointed out by Morrison
and Firmstone (2000), the main purpose of trust is to reduce uncertainty by bet-
ter managing risk and simplifying the process of choice. In this regard, the staff’s
professional appearance, friendliness and interest in the donor, facility cleanliness
13
or promptness, among other factors, influence the creation of donor trust, therefore
helping to reduce the said uncertainty. That is why it is important that the transfu-
sion centre makes an effort to inspire the donor with trust, thus increasing donor loy-
alty which is the ultimate objective. To sum up, this study’s results confirmed that
optimal management of each service encounter with the donor has several positive
consequences. These consequences eventually lead to greater donor loyalty, based
on quality criteria that foster donor satisfaction and trust.
5.2 Practical implications
Optimal management of the donation experience requires implementing excellence

criteria, with the aim of improving service quality, donor satisfaction and trust, and
the donor’s willingness to repeat and recommend the experience. For this, the dona-
tion centre must set service objectives and indicators to guarantee good service dur-
ing the donation process. Based on the dimensions and attributes described in the
quality scale which is validated in this study, both key external (front-office) and
internal (back-office) measures and protocols can be established. Given that they
provide a service that involves a close contact with the donor, the staff are largely
responsible for the success of the donation process. For this reason, the staff should
stay professional and attentive at all times, which requires they be qualified with
necessary technical and social skills. At a technical level, the donation centre staff
should always be familiar with current clinical protocols, techniques and standard
practices (e.g. use of clinical tools, safety protocols). Moreover, they should have
the necessary technical training to carry out their duties and, of course, always have
the required information about the donor’s history. As for social skills, the staff
should be friendly, always answer the donors’ questions, be sensitive to their emo-
tional state to anticipate their actions and calm them down whenever necessary, con-
vey the importance of donating throughout the entire process and thank donors for
their time and efforts at the end. Empirical data specifically highlight as an area for
improvement the staff’s constant showing of gratitude to the donor. Concerning the
role of human resources, as indicated by Martín-Santana and Beerli-Palacio (2012),
during the selection and training process of the donation centre staff, it is impor-
tant to focus on their technical competences and capacity to empathise and create a
secure environment when interacting with donors. In order to involve the staff, fol-
lowing the recommendations of the EFQM 2013 Model (European Foundation for
Quality 2012) for excellent organisations, donation centres should foster a ‘service
culture’. Thus they should teach employees how important it is for the donor to be
completely satisfied with service quality during the donation process. Based on the
literature on high performance human resource practices aimed at service quality
(Hong et al. 2017), it would be best to design an incentive scheme that recognises
the good work of transfusion centre staff, as well as their involvement in service
improvement projects. On the other hand, it should be noted that the study data indi-
cated a large margin for improvement in the Post-Donation dimension. This is abso-
lutely essential because, to a certain extent, this dimension measures the impact or
the immediate result for the donor, which could increase perceived value and trust in
13
the donation centre. It is recommended to make the centre’s appreciation tangible by

sending thank-you letters or messages. It could also be advisable to deliver clinical
reports and suggestions that might be interesting to the donor. Other factors that may
present significant obstacles to donation success are service times and the physi-
cal location of centres. Service time should be set correctly, and transfusion centres
should be located close to key geographical points (e.g. public services, shopping
centres and main streets) that are clearly identifiable or signalled and accessible (e.g.
near main roads or the public transport network). These measures can reduce the
inconvenience of donation. Thus they would turn into blood donation facilitators
(Martín-Santana and Beerli-Palacio 2012) and increase the quality perceived with
regard to donors’ timetables (Martín-Santana and Beerli-Palacio 2012; Jain et al.
2015). Obviously, these aspects relate more to waiting times in the donation process
rather than to increasing how quickly the staff perform their jobs, which might not
be recommendable in such a sensitive service. Optimised times are achieved with
appropriate scheduling of donations and the necessary staff levels. Several authors,
such as Saha and Bhattacharaya (2019), highlighted how important it is to reduce
waiting times for the donor. Waiting times do not only affect donors’ perception of
the system’s quality, but also can increase their anxiety and cause them to leave. In
line with the above, the results of this research emphasised the necessity for improv-
ing schedule flexibility and diminishing waiting times in the donation process.
On one hand, the dimensions and attributes of the validated quality scale have
become a point of reference to define measures aimed at fostering donor trust.
Explaining the donation process to donors and accurately answering their every
question calms them down. On the other, although recruitment strategies should
focus on motivating potential donors and educating the population to reduce per-
ceived barriers (Boenigk et al. 2011), it is also important to publish data about the
purpose of blood banks. The donation system should also give estimated forecasts
about future uses and available deposits in order to increase trust in transfusion cen-
tres. In this sense, Hao Suan Samuel et al. (2015) suggested that trust is the belief
that the organisation will not act incorrectly. This is why it is necessary to diminish
uncertainty and information asymmetry, since both these factors increase the per-
ceived risk. With this in mind, in the blood donation context, Chen (2017) recom-
mends publishing information on the use of blood as evidence of public transpar-
ency, given its effect on trust consolidation. To sum up, donation management must
be understood as an individual service (the provision itself), which has to be pro-
vided in an optimal way for a social purpose.
5.3 Study limitations and future lines of research
It would be necessary to study other measures that are closely related to donor loy-
alty. In this sense, including anticipated emotions to anticipate future behaviour
(especially, of first-time donors) could provide additional data on loyalty to the
donation centre. Moreover, it would be advisable to study inactive donors, who have
been outside the system for more than two years, in order to know whether there are
13
significant differences in the causal relationships considered in this research. Furher,

it would be very interesting to carry out longitudinal studies to analyse the evolution
of these relationships over time. It should also be studied how successful strategies
are when applied by transfusion centres to improve service quality, as well as what
their influence is on the donor-related result indicators considered here. As a final
note, it would be necessary to include additional items to the Loyalty construct to
improve its reliability.
Acknowledgements This work was supported by the Spanish Ministry of Economy and Competitiveness
(Project ECO2015-64875-R).
Author contributions All authors contributed to study conception and design, material preparation, data
collection and analysis, and manuscript drafting and revision. All authors read and approved the final
manuscript.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of interest.
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Service Business (2020) 14:101–129

Service quality in blood donation: satisfaction, trust

Keywords Blood donation · Service quality · Satisfaction · Trust · Loyalty

Blood is perceived as a very valuable resource to addressing healthcare needs and

2 Theoretical background and hypotheses

2.1 Blood donation as a complex service: from recruitment to loyalty

managers should encourage donors to recommend others to donate. Moreover, the

2.2 Donation process: measuring service quality

2.3 Service quality and its result indicators in donors: satisfaction with donation

2.3.1 Satisfaction with donation experience

Whereas quality is associated with service excellence or superiority, satisfaction is

H2 Service quality positively influences the donor’s attitudinal loyalty.

H3 A satisfactory donation experience positively influences the donor’s attitudinal

H4 Service quality positively influences trust in the organisation.

There is empirical evidence supporting the relation between donor satisfaction

H5 Donor satisfaction positively influences trust in the organisation.

Table 1 Sample profile Characteristics N %

Personal Attention and Pro- SQ8 The staff perform well

Constructs Code Items

4.1 Analysis of the validity of the measurement scales

4.1.1 Validation of the scale of service quality

Table 3 Confirmatory factor analysis of service quality

Fit measures: χ2(115) = 12,762.500, p = 0.000, CFI = 0.957, NFI = 0.957, RMSEA = 0.060

SQ1 ← TANG 0.685 124.568 0.000 CR = 0.828

SQ4 ← ACCE 0.549 76.526 0.000 CR = 0.725

SQ8 ← PA&P 0.773 124.136 0.000 CR = 0.931

SQ15 ← PD 0.541 96.181 0.000 CR = 0.828

Table 4 Confirmatory factor analysis of trust and loyalty

Fit measures: χ2(17) = 471.552, p = 0.000, CFI = 0.997, NFI = 0.996, RMSEA = 0.028

L1 ← INT 0.521 CR = 0.597

L3 ← RECOM 0.857 CR = 0.853

T1 ← TRUST 0.869 CR = 0.896

4.1.2 Validation of the scales of trust and loyalty

The reduced number of items intended to measure loyalty as a second-order model

Table 5 Evaluation of the Constructs Mean (SD) 1 2 3 4

most important performance variables in blood donation. Blood transfusion cen-

4.1.3 Descriptive analysis of service quality

***p < 0.01 GOODNESS OF FIT

Χ 2(288)= 17667.915 ( p=0.000), CFI = 0.960, NFI = 0.960, RMSEA = 0.044

Fig. 2 Results of the proposed model

Table 7 Differences in average values according to donor age

Service 6.11 6.01 6.06 6.11 6.20 97.889 1–2

Trust 6.56 6.53 6.54 6.55 6.60 18.405 1–4

Satisfaction 6.62 6.48 6.57 6.64 6.70 107.891 1–2

Loyalty 6.22 6.27 6.27 6.19 6.19 16.753 1–3

Optimal management of the donation experience requires implementing excellence

the donation centre. It is recommended to make the centre’s appreciation tangible by

5.3 Study limitations and future lines of research

significant differences in the causal relationships considered in this research. Furher,

Compliance with ethical standards

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2 Theoretical background and hypotheses

2.1 Blood donation as a complex service: from recruitment to loyalty

2.2 Donation process: measuring service quality

2.3 Service quality and its result indicators in donors: satisfaction with donation

2.3.1 Satisfaction with donation experience

Table 1 Sample profile Characteristics N %

4.1 Analysis of the validity of the measurement scales

4.1.1 Validation of the scale of service quality

Table 3 Confirmatory factor analysis of service quality

Table 4 Confirmatory factor analysis of trust and loyalty

4.1.2 Validation of the scales of trust and loyalty

Table 5 Evaluation of the Constructs Mean (SD) 1 2 3 4

4.1.3 Descriptive analysis of service quality

Fig. 2 Results of the proposed model

Table 7 Differences in average values according to donor age

5.3 Study limitations and future lines of research