Money matters: The association between blood donation rates and healthcare system quality across 171 countries.

BACKGROUND: Worldwide, insufficient blood donations cause blood shortages that jeopardize vital medical treatments for patients. Blood donation rates vary widely across countries, yet the determinants of this variation remain poorly understood. This study aims to illuminate the role of the institutional context in which blood donation is embedded by examining the link between country-level blood donation rates and healthcare system quality. STUDY DESIGN AND METHODS: The study employed a cross-sectional design using data on blood donation rates from 171 countries from the 2021 WHO Global Status Report on Blood Safety and Availability and three healthcare quality indicators (i.e., Healthcare Access and Quality [HAQ] Index, life expectancy, and health expenditures). The pre-registered hypotheses are tested using multiple linear regression. Robustness checks control for confounding factors. RESULTS: HAQ Index and health expenditures are positively associated with blood donation rates, whereas life expectancy is not related to blood donation when controlling for confounds. Health expenditures display the most robust association with blood donations, even when controlling for confounding factors, and when comparing countries within the same continent. CONCLUSION: Higher healthcare system quality in terms of HAQ Index and higher healthcare expenditures are related to higher blood donation rates. The finding that healthcare expenditures are most consistently related to blood donation rates indicates that policymakers should consider prioritizing financial support for the healthcare system, including blood-collecting institutions. More broadly, a better understanding of the role of contextual factors for blood donation may be needed to increase blood availability worldwide.

Incentives for plasma donation.

BACKGROUND AND OBJECTIVES: This work provides an overview of the incentives used for plasma donation in Europe and beyond. The overview can provide new ideas to blood establishments. MATERIALS AND METHODS: We conducted a systematic online search of incentives used and asked national experts to validate the data across all European Union countries as well as other European and non-European countries. We categorized the data into level of incentive (using the Nuffield Council on Bioethics' rungs [2011]) and country. RESULTS: We analysed more than 490 organizations across 26 countries. Our findings reveal different incentives used in these countries. Snacks and pre-donation health checks are commonly provided. In addition, loyalty programmes, small gifts, vouchers, lotteries, travel compensations and time off from work extend the strategic incentive portfolio. Only seven countries offer financial compensation ranging from the equivalent of 10-35€ for European countries. In countries with a decentralized model, where more than one organization collects plasma, we observe that more diversified incentive strategies are generally used, including monetary and non-monetary incentives. In countries with a centralized model, where only one organization is allowed to collect plasma, financial compensation is usually not offered. Centralized plasma collection without financial compensation relies on a wider range of non-monetary incentives than with financial compensation. CONCLUSION: The country group analysis offers valuable insights into the relationship between incentive strategies and the prevailing centralized versus decentralized plasma collection model. This overview provides a broader understanding of incentives used by blood establishments and offers avenues for future practice.

New blood donors in times of crisis: Increased donation willingness, particularly among people at high risk for attracting SARS-CoV-2.

BACKGROUND: Traditionally, during crises the number of new blood donors increases. However, the current coronavirus disease 2019 (COVID-19) pandemic created additional barriers to donate due to governmental prevention measures and increased personal health risks. In this report, we examined how the pandemic affected new donor registrations in the Netherlands, especially among groups with higher risk profiles for severe COVID-19. Additionally, we explored the role of media for blood donation and new donor registrations. STUDY DESIGN AND METHODS: We analyzed new donor registrations and attention for blood donation in newspapers and on social media from January until May 2020, in comparison to the same period in 2017 to 2019. RESULTS: After the introduction of nationwide prevention measures, several peaks in new donor registrations occurred, which coincided with peaks in media attention. Interestingly, people with a higher risk profile for COVID-19 (e.g., due to age or region of residence) were overrepresented among new registrants. DISCUSSION: In sum, the first peak of the current pandemic has led to increased new blood donor registrations, despite the associated increased health risks. Time and future studies will have to tell whether these new donors are one-off 'pandemic' donors or if they will become regular, loyal donors.

Validation of a standardized donor health questionnaire across substances of human origin.

BACKGROUND AND OBJECTIVES: A donor health questionnaire (DHQ) aims to ensure the safety of donors and recipients of transfusions or transplantations with blood components, plasma-derived medicinal products, tissues, haematopoietic stem cells and medically assisted reproduction (in short substances of human origin; SoHO). Currently, many different DHQs exist across countries and SoHO. TRANSPOSE (TRANSfusion and transplantation PrOtection and SElection of donors) developed and validated a standardized DHQ to use across countries and SoHO. We tested whether participants understand the questions and provide honest answers. METHODS: For the validation of the standardized DHQ, two demographically representative online surveys were conducted in Germany (N = 3329) and Austria (N = 3432). We surveyed whether participants understood each DHQ question and would answer the questions truthfully. We used experimental settings to test whether there is a difference between mode of administration (print vs. online), the order of the questions (subject vs. chronological order), and the positioning of the general state of health question (beginning vs. end) in the DHQ. Using regression models, we tested the DHQ's impact on participant mood after completion and on socially desirable response behaviour. RESULTS: Participants understood the DHQ questions well and would answer them honestly. Nevertheless, the data show different levels of understanding and honesty when responding. Administration mode was the only characteristic that had a significant influence on mood, with the online version resulting in a more favourable mood in comparison to the printed version. CONCLUSION: The DHQ was well understood and had a low dishonest tendency. Our findings can serve as an impulse for further research on DHQ criteria across other SoHO and countries.

How donor selection criteria can be evaluated with limited scientific evidence: lessons learned from the TRANSPOSE project.

BACKGROUND AND OBJECTIVE: Donor selection criteria (DSC) are a vital link in the chain of supply of Substances of Human Origin (SoHO) but are also subject to controversy and differences of opinion. Traditionally, DSC have been based on application of the precautionary principle. MATERIALS AND METHODS: From 2017 to 2020, TRANSPOSE (TRANSfusion and transplantation PrOtection and SElection of donors), a European research project, aimed to identify discrepancies between current DSC by proposing a standardized risk assessment method for all SoHO (solid organs excluded) and all levels of evidence. RESULTS: The current DSC were assessed using a modified risk assessment method based on the Alliance of Blood Operators' Risk-based decision-making framework for blood safety. It was found that with limited or diverging scientific evidence, it was difficult to reach consensus and an international standardized method for decision-making was lacking. Furthermore, participants found it hard to disregard their local guidelines when providing expert opinion, which resulted in substantial influence on the consensus-based decision-making process. CONCLUSIONS: While the field of donation-safety research is expanding rapidly, there is an urgent need to formalize the decision-making process regarding DSC. This includes the need for standardized methods to increase transparency in the international decision-making process and to ensure that this is performed consistently. Our framework provides an easy-to-implement approach for standardizing risk assessments, especially in the context of limited scientific evidence.

Barriers to blood donation on social media: An analysis of Facebook and Twitter posts.

BACKGROUND: To better understand donor behavior and ensure a safe and sufficient blood supply, various observational studies have examined barriers to blood donation. This study used Facebook and Twitter data to enhance existing research on donation barriers and associated emotions communicated on social media by both donors and non-donors. STUDY DESIGN AND METHODS: We conducted a semantic network analysis (SNA) with 168 232 public Dutch language social media messages from Facebook and Twitter during 2012-2018. SNA uses concepts as nodes in a network and the relationship (ie, co-occurrence) as links between them. We identified the relationship between donation barriers, non-donation (voluntary and involuntary), and dissatisfaction (anger and disappointment) within social media messages. This computational method was combined with an analysis examining significant relationships in-depth. RESULTS: Twelve donation barriers were identified: lifestyle, donation location, medical reasons, no invitation, opening times, physical reactions, pregnancy, remuneration, sexual risk behavior, time constraints, travels, and waiting times. More messages related to involuntary non-donation compared to voluntary non-donation. Involuntary non-donation was associated most strongly with medical reasons and sexual risk behavior, while voluntary non-donation was associated most strongly with resentment regarding remuneration of the blood bank's top management. Anger associated most strongly with sexual risk behavior and disappointment most strongly with medical reasons. CONCLUSION: Discussions around blood donation are increasingly taking place online. Donation barriers found in this study differ from those in survey research. Insights into how donation barriers are communicated in an ever-growing online environment can be utilized to enhance recruitment and retention strategies.

The impact of age and sex on first-time donor return behavior.

BACKGROUND: This study examined the impact of age and sex of first-time donors who had not experienced an adverse event or deferral on their likelihood of and time to return. STUDY DESIGN AND METHODS: On behalf of the Biomedical Excellence for Safer Transfusion (BEST) Collaborative, international blood collection agencies (BCAs) were invited to provide data on first-time whole blood donors in 2014, including initial presentation date, collection site type, age, sex, blood type, return to donate within 24 months (yes/no), and subsequent presentation date. RESULTS: Eight BCAs contributed 706,789 records. The overall odds of returning to donate were slightly lower in female versus male donors, and the overall age trend was U-shaped with younger and older donors having higher odds for returning relative to middle-aged donors. However, variations by BCA were observed. Specifically, in three BCAs, women had higher odds of returning to donate than men. Further, while across seven BCAs the smallest cohort of older first-time donors returned at a higher rate and returned more quickly than middle-aged first-time donors, the behavior of younger donors varied substantially between BCAs. CONCLUSION: While older first-time donors are more likely to return and return more quickly than middle-aged donors they make up only a small proportion of first-time donors, whereas the larger group of younger donors exhibits less clear patterns of return compared to middle-aged donors. Further research is needed to determine whether targeting the recruitment of older donors or bolstering retention of middle-aged donors would be most effective in maintaining the blood supply.

Beyond Description: The Predictive Role of Affect, Memory, and Context in the Decision to Donate or Not Donate Blood.

BACKGROUND: Research on the recruitment and retention of blood donors has typically drawn on a homogeneous set of descriptive theories, viewing the decision to become and remain a donor as the outcome of affectively cold, planned, and rational decision-making by the individual. While this approach provides insight into how our donors think about blood donation, it is limited and has not translated into a suite of effective interventions. In this review, we set out to explore how a broader consideration of the influences on donor decision-making, in terms of affect, memory, and the context in which donation takes place, may yield benefit in the way we approach donor recruitment and retention. SUMMARY: Drawing on emerging research, we argue for the importance of considering the implications of both the positive and the negative emotions that donors experience and we argue for the importance of directly targeting affect in interventions to recruit nondonors. Next, we focus on the reconstructed nature of memory and the factors that influence what we remember about an event. We discuss how these processes may impact the retention of donors and the potential to intervene to enhance donors' recollections of their experiences. Finally, we discuss how our focus on the individual has led us to neglect the influence of the context in which donation takes place on donor behavior. We argue that the amassing of comprehensive large data sets detailing both the characteristics of the individuals and the context of their giving will ultimately allow for the more effective deployment of resources to improve recruitment and retention. KEY MESSAGES: In suggesting these directions for future research, our want is to move beyond the ways in which we have traditionally described blood donation behavior with the aim of improving our theorizing about donors while improving the translational value of our research.

(Non-)donor demographics, donation willingness, and the donor career.

Donation willingness is generally high but registering with donor centers lags behind. We need to understand why and when during the life course which groups of individuals are motivated to donate. With this knowledge, we can design targeted recruitment and retention strategies and improve evidence-based donor management.

Do deferred donors continue their donations? A large-scale register study on whole blood donor return in the Netherlands.

BACKGROUND: Temporary deferral of whole blood donors is essential for a safe blood supply, yet deferral may impact donor return. Different deferral reasons may differently affect return, and donor experience may interfere with this. Therefore, we studied the joint effect of deferral reason and donor experience on return. STUDY DESIGN AND METHODS: We used a large-scale retrospective cohort design including all Dutch donors with a whole blood donation attempt in 2013 to 2015 (n = 343,825). We established details of the target donation (including deferral reason if applicable), details of attendances in the 2 years after the target donation, donor characteristics (blood type, sex, age), and donor experience (first-time, novice, experienced, reactivated). Descriptive statistics as well as time-to-events methods were used. RESULTS: Experienced donors were most likely to return, even after deferral (nondeferred 96% vs. deferred 92%). First-time and reactivated donors were less likely to return after deferral (69 and 61%, respectively) compared to their nondeferred counterparts (82 and 76%, respectively). First-time hemoglobin (Hb)-deferred donors were less likely to return and slower to return than other donors. Similar results were found for reactivated donors deferred for short-term medical reasons. CONCLUSION: Deferral reason and donor experience individually as well as jointly impacted donor return. Particularly first-time and reactivated donors were at risk of nonreturn, especially when deferred for Hb or short-term medical reasons, respectively. Blood banks designing and implementing donor retention strategies should thus not only take successful but also unsuccessful donation experiences and different experience levels into account.

Deferral rate variability in blood donor eligibility assessment.

BACKGROUND: Both donors and the blood bank rely on the result of the donor health interview. However, survey data suggest that substantial variability in deferral rates among interviewers exist. We studied whether variability remained after adjusting for conditional factors. STUDY DESIGN AND METHODS: The data set included Dutch interview data on whole blood donor visits in 2015, where one of their visits was selected randomly. We applied logistic regression and multilevel regression analyses with the donor visit, with the interviewer representing the levels. We set up four models: 1) all reasons deferral, 2) low-hemoglobin-level deferral, 3) infectious disease risk deferral and 4) other medical reasons deferral. RESULTS: In total, 138,398 visits were included in the study, of which 60,534 (43.7%) related to male donors. The overall deferral rate for men was 7.91% and for women 12.25%. Deferral rates among interviewers ranged from as low as 1.19% up to 28.8%. Models 2 (low hemoglobin level) and particularly 4 (other medical reasons), for both men and women, showed significant intraclass correlation coefficients, implying considerable deferral rate variability among interviewers. Donor age, the number of previous visits, and the season had relatively large effects. However, explained variances of the logistic regression models were relatively low, ranging from 2.53% to 7.35%. CONCLUSION: Deferral appears to be a random process, while substantial variability was found among interviewer deferral rates, suggesting that some interviewers are more cautious than others. Our results suggest heuristic and subjective diagnosing to be prevalent. Steps should be taken to improve interview result validity.

Determinants of blood donation willingness in the European Union: a cross-country perspective on perceived transfusion safety, concerns, and incentives.

BACKGROUND: Willingness to donate blood depends on personal characteristics, beliefs, and motivations, but also on the cultural context. The aim of this study was to examine whether willingness to donate blood is associated with attitudes toward blood transfusion, personal motivators, and incentives and whether these factors vary across countries in the European Union (EU). STUDY DESIGN AND METHODS: The sample consisted of 27,868 participants, from 28 EU member states, who were interviewed about blood donation and transfusion-related issues for the 2014 round of the Eurobarometer, a country-comparative survey, collected on behalf of the European Commission. Participants were asked whether they would be willing to donate blood and for which reasons (motivators) and which incentives are appropriate to receive in return for a blood donation. RESULTS: Willingness to donate varied significantly across countries and was positively associated with perceived blood transfusion safety. Furthermore, helping family or people in need were the most powerful motivators for blood donation willingness in almost all countries. In contrast, the number of participants who were willing to donate to alleviate shortages or to contribute to research varied widely across countries. The wish to receive certain incentives, however, did not seem to be related to willingness to donate. CONCLUSION: Perceived blood transfusion safety and personal motivations may be stronger determinants of willingness to donate than receiving certain incentives. EU-wide strategies and guidelines for donor recruitment and retention should take both overall and country-specific patterns into account. For example, education on the importance of donation could be considered.

Life events and donor lapse among blood donors in Denmark.

BACKGROUND AND OBJECTIVES: The likelihood of donating blood changes over the life course, with life events shown to influence entry to and exit from the donor population. While these previous findings provide valuable insights for donor management, blood collection agencies need to be cautious about generalizing findings to other countries as blood donor behaviour is context-specific. To examine cross-country variations in donor behaviour, the repeatability of a previous Dutch study on life events and blood donor lapse is examined by using a sample of Danish donors. MATERIALS AND METHODS: Register data from Statistics Denmark was linked to the Scandinavian Donations and Transfusions database (n = 152 887). Logistic regressions were conducted to examine the association between life events in 2009-2012 and blood donor lapse in 2013-2014. RESULTS: Of the total sample, 69 079 (45·2%) donors lapsed. Childbirth and losing a job increased the lapsing risk by 11% and 16%, respectively, while health-related events in the family (i.e. blood transfusion, disease and death) decreased the lapsing risk by 5%, 7% and 9%, respectively. CONCLUSION: Life events are associated with donor lapse of Danish donors. These results are comparable to previous findings from the Netherlands (i.e. childbirth and labour market transitions increased lapsing risk; health-related events decreased lapsing risk), with two thirds of the associations being in the same direction. Differences between study results were mainly related to effect sizes and demographic compositions of the donor pools. We argue contextual factors to be of importance in blood donor studies.

Donor InSight: characteristics and representativeness of a Dutch cohort study on blood and plasma donors.

BACKGROUND AND OBJECTIVES: More insight into donor health and behaviour may contribute to more efficient and focused strategies regarding donor care and management. Donor InSight (DIS) is a Dutch cohort study of blood and plasma donors. We aimed to outline the objectives and methods of DIS, describe the cohort, and compare it to the active Dutch donor population. MATERIALS AND METHODS: In 2007-2009 (DIS-I, n = 31 338) and 2012-2013 (DIS-II, 34 826, of whom 22 132 also participated in DIS-I) questionnaire data on demographics, donation, lifestyle, family composition, health and disease were collected. A second follow-up (DIS-III, n = 3046), including donors with differing haemoglobin trajectories, was completed in 2015-2016. DIS-III includes data on genetic determinants, iron and red cell indices. Representativeness of the DIS-I sample for the entire Dutch donor population was assessed by comparing characteristics of both. RESULTS: Donor InSight was initially set up because of a need for more detailed information and evidence as a basis for decision-making in blood banks. DIS-I sample is comparable to the total Dutch donor population in terms of age, body mass index, haemoglobin level, blood pressure, blood type and donation behaviour. CONCLUSION: Donor InSight is a cohort study representative of the Dutch donor population. It provides evidence to support evidence-based decision making.

Psychosocial characteristics of blood donors influence their voluntary nonmedical lapse.

BACKGROUND: Approximately 10% of Dutch donors lapse yearly. Common reasons are nonvoluntary medical issues (e.g., low hemoglobin), reaching the upper age limit, and voluntary (e.g., own request, nonresponse). Little is known about predictors of voluntary noncompliance (lapses). Psychosocial characteristics have been linked to various health behaviors, including voluntary noncompliance. Hence, we investigated whether psychosocial characteristics, measured before the first donation, similarly predict subsequent voluntary nonmedical lapse. STUDY DESIGN AND METHODS: New donors (n = 4861) randomly received a blood donation survey between July 2008 and March 2009, before their first appointment at the blood bank. Voluntary lapses included personal reasons, nonresponse to invitations, donor who could not be reached, and no show. Univariate and multivariate Cox regression models of lapse on psychosocial characteristics and confounders (e.g., demographics) were estimated. RESULTS: Of 2964 donors who took the questionnaire, more than one-third (36.5%) had voluntarily lapsed due to nonmedical reasons by 2016. Univariate regression showed that lapse negatively associated with norms, attitudes, and intentions toward blood donation; self-efficacy; and more donation experience. Lapse positively associated with anxiety. Multivariate Cox models showed that lapse was primarily driven by anxiety and need for information. CONCLUSION: Certain psychosocial characteristics increase risks of voluntary lapse. Especially donors with higher donation anxiety had increased lapsing risks. They might benefit from extra attention during donation. Donors with more information need or wish about procedure and patients were less likely to lapse, indicating that binding with the blood bank might prevent lapse. Generally, this study showed that donor lapse and donor return are determined by different psychosocial factors not just the reverse of each other.

Eligibility and willingness to donate blood in men who have (had) sex with men.

BACKGROUND: Several countries have changed, or are reevaluating, their blood donor policies for men who have had sex with men (MSM). Changing policies has consequences for donor recruitment and the donor pool. In this study, we investigated whether MSM are eligible and willing to donate blood. STUDY DESIGN AND METHODS: Members of a research panel (n = 4422) in the Netherlands were invited to participate in an online survey. We asked questions about male-to-male sex and risk behavior that are also asked during the predonation screening of a blood donor. Furthermore, we asked questions about willingness to donate. RESULTS: The total response rate was 60% (n = 2654). Of MSM nondonors (n = 230), 32.2% would be eligible to donate under a 12-month deferral policy, according to their reported risk history and last male-to-male sex. In other scenarios, 42.6% (4-month deferral), 38.7% (6-month deferral), and 18.7% (5-year deferral) would be eligible to donate. When not taking their last male-to-male sex into account (n = 203), 47.8% of MSM reported a moderate or high willingness to donate. CONCLUSION: A 12-month deferral after last male-to-male sex is a commonly used criterion by blood services. Approximately one-third of the MSM in our study would be eligible to donate under this deferral policy. Higher proportions of MSM would be eligible to donate in shorter deferral scenarios. Almost half of MSM are willing to donate blood. Targeting MSM by donor recruitment campaigns could therefore prove fruitful.

Facilitators and barriers for RhD-immunized women to become and remain anti-D donors.

BACKGROUND: The successful introduction of prophylaxis with anti-RhD immunoglobulin has resulted in a significant decline of pregnancy-related RhD immunizations but also has decreased the availability of naturally immunized women as (new) anti-D donors. An influx of new donors is necessary to maintain a sufficient pool of anti-D donors. We investigated motivators, barriers, and predictors for anti-D donorship in RhD-immunized women. STUDY DESIGN AND METHODS: A mixed-methods design was applied, including focus group discussions and questionnaires. Two focus groups (including 11 women) served as input for the questionnaire. RESULTS: In total, 47.6% of 750 anti-D donors and potential donors completed the questionnaire (50.4% donors; 38% nondonors; 11.6% former donors). Almost 70% of the nondonors would have become donors if they had known about the possibility. Travel time investment was reported as a disadvantage; one-half of donors mentioned no disadvantages. Motivators for anti-D donorship were "doing something in return" (31.2%) and "preventing others having a sick child or losing a child" (33.9%). In multivariable analysis, living single (odds ratio, 5.8; p = 0.02) and living partnered without resident children (odds ratio, 7.9; p = 0.03), compared with living partnered with children, were predictors for anti-D donorship. Not being registered as an organ donor (odds ratio, 0.25; p < 0.001) predicted that the individual would not be an anti-D donor. CONCLUSION: The main barrier for anti-D donorship was a lack of knowledge. Positive predictors of anti-D donorship were living without resident children, altruism, and being registered as an organ donor. A blood bank should develop targeted recruitment strategies with a focus on spreading knowledge about anti-D donorship among RhD-immunized women.

Organ Donation Registration and Decision-Making Among Current Blood Donors in the Netherlands.

INTRODUCTION: In the Netherlands, there is a constant shortage in donor organs, resulting in long waiting lists. The decision to register as organ donor is associated with several demographic, cultural, and personal factors. Previous research on attitudes and motivations toward blood and organ donations provided similar results. RESEARCH QUESTION: The current study investigated demographic, cultural, and personal determinants of organ donation registration among current Dutch blood donors. DESIGN: We used data from Donor InSight (2012; N = 20 063), a cohort study among Dutch blood donors, to test whether age, gender, religious and political preferences, donor attitude, and altruism predicted organ donor registration among current blood donors. RESULTS: Organ donors were more often represented in the blood donor population compared to the general Dutch population. Women showed a higher propensity to be registered as organ donor. Higher education as well as higher prosocial value orientation, prosocial behavior, that is, doing volunteer work, and awareness of need significantly associated with being registered as organ donor. Religious denomination negatively predicted organ donation registration across all faiths. DISCUSSION: Results are discussed in light of cultural context, and possible implications for improving information provision and recruitment are mentioned.

Mothers' Mobility after Separation: Do Grandmothers Matter?

Starting from a life course perspective, this study aims to gain more insight into mobility patterns of recently separated mothers, focusing especially on moves to the location of their own mother: the maternal grandmother. Separated mothers, having linked lives with their own mothers, may benefit from their practical and emotional support. Additionally, the grandparents' home can be a (temporary) place to stay shortly after divorce. Data come from the System of social statistical datasets (Statistics Netherlands). This unique dataset combines longitudinal data from a vast number of administrative registers. It covers the complete Dutch population, making it exceptionally well suited for life course and mobility research. We studied mothers with minor children between 1/1/2008 and 31/12/2010. Our study included 579,500 mothers, of whom about 8,800 (1.5%) experienced a separation in 2008. Separated mothers moved to the grandmother's municipality more often than non-separated mothers, which might be partially motivated by the need for childcare. They also coresided with the grandmother more than non-separated movers, mostly because of a vulnerable socio-economic position. Although often temporary, coresidence appears to have a prolonged impact on the mothers' location choice; mothers frequently stayed in the grandmother's municipality after moving out. Finally, our results indicated that some mothers seemed to use the parental home as a stepping stone to cohabit with a new partner. © 2016 The Authors. Population, Space and Place published by John Wiley & Sons Ltd.