Systemic barriers to donation for African, Caribbean and Black communities: A qualitative key informant study

Abstract

Background and Objective

For many blood collection agencies (BCAs), meeting the transfusion needs of people living with sickle cell disease, a genetic condition that causes sickling of red blood cells, is a priority but also a challenge because of a lack of diversity in the donor base. To help address this challenge, this study aimed to understand systemic barriers to donation from the perspectives of African, Caribbean, and Black (ACB) community leaders.

Methods and Materials

A qualitative study informed by a community‐based participatory research approach was conducted with 10 ACB community leaders across Canada. Semi‐structured interviews were conducted with key informants from February to March 2023. Topics explored included community involvement and priorities, perspectives on racism and discrimination, and perspectives on blood and other forms of donation including challenges to donation and recommendations for addressing challenges. Interviews were audio‐recorded with participants' consent, transcribed, and uploaded to NVivo for analysis. Data analysis was guided by an interpretive descriptive and thematic analytic approach.

Results

Our analysis demonstrates how differing sociocultural views on blood donation, mistrusting BCAs as an extension of healthcare systems, and experiences of deferral criteria as exclusionary are constructed as barriers to donation for some ACB people and communities.

Conclusions

Easing deferral criteria was recommended by key informants as a necessary step towards addressing a significant barrier to donation; however, even with the removal of a permanent deferral, its legacy and impact on affected communities may remain. Recommendations include that BCAs collaborate with ACB community groups to address these barriers.

1. INTRODUCTION

For many blood collection agencies (BCAs), meeting the treatment needs of people living with sickle cell disease (SCD), a genetic condition that causes sickling of red blood cells, is both a priority and a challenge. Treatment options for some living with SCD include regular red cell exchange which can require 8 units of blood every 4 weeks. ¹ , ² , ³ While SCD can affect anyone, it is known to be more prevalent in people of African, Middle Eastern, Mediterranean, Central and South American, and South Asian descent. ⁴ For people on red cell exchange therapy, prophylactic matching for some red cell antigens is routinely done by many institutions. If patients develop red cell antibodies, they may require either rare antigen combinations or red cells missing a common antigen, both understood to be more commonly found in donors of similar genetic background. ² , ⁵ , ⁶ While genotyping donors and recipients offers the most complete matching, currently BCAs do not genotype all donors. ⁷ Instead, many use a donor's expressed ethnicity or race to direct which donations undergo extended geno‐ or pheno‐typing. While ethnicity or race (social constructs) do not determine blood antigens nor does ethnically‐matched blood necessarily lead to better outcomes for recipients, ⁸ , ⁹ donor ethnicity is currently used as a proxy to guide the use of limited typing resources. Haematopoietic stem cell transplantation also requires stringent HLA matching between donors and recipients. International unrelated donor registries, whether for cord blood or adult potential donors of bone marrow or peripheral blood stem cells, do not have sufficient donors from ACB communities to meet patient needs. ¹⁰ As such, it is important for BCAs and stem cell registries to have an ethnically and genetically diverse donor base.

In Canada, donors who identify as African, Caribbean, or Black (ACB) make up less than 1% of the blood donor base and 4.3% of the Canadian population with this percentage expected to grow over the next decade. ¹¹ As such, ACB donors are under‐represented in the blood donor base proportionate to their representation in the Canadian population. The Sickle Cell disease Association of Canada (SCDAC), a national advocacy organisation for people living with SCD, estimates that ~6500 people in Canada live with SCD with most identifying as ACB. ¹² For many years, SCDAC has worked to increase awareness of blood donation in ACB communities, including collaborating with BCAs in Canada–Canadian Blood Services (CBS) and Héma‐Québec. Despite these efforts, recruiting ACB donors continues to be a challenge.

A prior study on ACB young adults in Canada applied a socio‐ecological framework and found that higher‐order or systemic barriers, such as mistrust and racism, were found to influence and shape lower‐order—that is, organisational or personal level—barriers. ¹³ Results suggest that: (1) barriers do not act as isolated factors but inform and interact with one another; and (2) more attention is needed to understand barriers at the systemic level. ¹³ Building on this work, the present study focused on understanding systemic barriers to donation from a community perspective.

1.1. Theoretical approach

This project was guided by an interpretivist epistemology that views the social domain as constructed by people's experiences, ideas, meaning making, and interactions. ¹⁴ People's actions and perceptions can never be separated from the broader context and as such voluntary blood donation is viewed as a social act embedded in sociocultural, economic, and political context. Consistent with this approach, barriers are constructed and emerge from the conditions, context, and perceptions of the people and communities involved. Exploration of the broader context, then, provides greater understanding of the conditions that contribute to the construction of barriers.

2. STUDY DESIGN AND METHODS

We conducted a qualitative study with data generated from semi‐structured, in‐depth interviews with 10 key informants who are ACB community leaders. This study was guided by community‐based participatory research (CBPR) principles including shared power and decision‐making between researchers and community partners. ¹⁵ , ¹⁶ The President of SCDAC was on the research team as a coinvestigator and was involved in every stage of this study. This study aimed to: (1) examine systemic barriers and enablers to donation of blood, plasma, stem cells, and organs and tissues for ACB communities from the perspective of community leaders; and (2) provide recommendations to BCAs. Research Ethics Board approvals were provided by CBS and the University of Victoria.

Approaching donation as a socially embedded process with decisions to donate mediated by community context, we identified community leaders as expert key informants who could speak to their own experiences and offer insights on their community. ¹⁷ Scholars recommend critical reflection on the definition of ‘community’ and who counts as an ‘expert’ and have cautioned that formal leaders in any community may hold and share dominant views without consideration of ‘everyday experts’. ¹⁸ For this reason, we did not begin with an a priori definition of ‘community’ or ‘community leader’ (e.g., someone who holds a formal leadership position). Instead, we allowed participants to self‐identify as a leader and describe their communities as they understood them. Communities included cultural, faith‐based, healthcare, and employment‐focused groups and organisations that serve ACB people. Participants were offered a $25 e‐gift card.

2.1. Participant recruitment

A purposive sampling strategy was applied, and key informants were recruited through research team networks. Eligibility criteria included identifying as ACB and a community leader, and comfortable communicating in English. Key informants were not required to have donated but to have an interest in and thoughts on donation. Sufficient sample size for key informant interviews can range with some studies including less than 10 at the lower end. ¹⁹ Sample size is determined by the approach taken and the aims of the study. ²⁰ Taking an interpretivist approach, we applied the concept of ‘information power’ (i.e., the more information that a sample provides for the question under study, the smaller the sample size needed) to inform the sample size. ¹⁷ , ²⁰ Because key informants offer perspectives beyond their own personal experiences, these studies often have smaller sample sizes than other qualitative studies. We do not claim that our sample size offers generalisable results, nor do we claim that it presents the views of all ACB communities across the country; however, our sample provides sufficient information power to offer insights into our topic of interest.

2.2. Data collection

Semi‐structured interviews were conducted with key informants in February–March 2023. All interviews were 30–60 min in length, conducted on a videoconferencing platform and audio‐recorded with participants' consent. Topics explored in the interview included community involvement and priorities, perspectives on racism and discrimination, and perspectives on blood and other forms of donation including challenges to donation and recommendations for addressing challenges. These topics were explored both from their personal and community's perspectives. Interviews were transcribed, and key informants were given the option to review their transcripts for member checking. Transcripts were uploaded to NVivo for data analysis.

2.3. Data analysis

Data analysis was guided by an interpretivist descriptive and thematic analytic approach. ²¹ , ²² , ²³ Two research team members (J.S. and J.H.) read all the interview transcripts to become immersed in and familiar with the data. J.S. and J.H. read each transcript independently and met weekly to discuss themes in the interviews. Reading through each transcript multiple times, J.S. and J.H. took extensive notes before proceeding to code. A codebook was developed with both deductive and inductive codes and modified as coding progressed.

3. RESULTS

3.1. Study participants

All key informants were women, aged 20s–60+, and identified with a range of ethnicities (see Table 1). Women in many ACB communities assume a leadership role ²⁴ ; therefore, that all participants were women may reflect the cultural realities of these communities. All had heard of blood donation, with some having donated; some had heard about stem cell and organ and tissue donation, and only a few were familiar with plasma donation (see Table 2). Key informants were much more familiar with blood donation than other forms of donation, and their discussions of barriers to donation and their experiences with and knowledge of BCAs were mostly in relation to blood donation. As such, our results are specific to blood donation unless otherwise specified.

TABLE 1.

Participant sociodemographic details.

Demographic variable	N
Self‐identified gender
Woman	10
Age group
20–29	2
30–39	3
40–49	3
50–59	1
60+	1
Self‐identified ethnicity/ancestry
African	2
Black	1
Caribbean	1
Nigerian	2
Congolese	2
Mixed/bi‐racial	2
Migration history
First generation (born in another country and moved to Canada)	7
Second generation (born in Canada and parents born in another country)	1
Third+ generation (both participant and parents—and possibly prior generations – born in Canada)	1
Not reported	1
Province
British Columbia	1
Nova Scotia	1
Ontario	4
Saskatchewan	1
Quebec	3

TABLE 2.

Experiences with and knowledge of donation.

Donation experience	N
Blood donation
Donor (donated at least one time)	3
Attempted to donate	2
No experience with donation	5
Plasma donation
No experience with plasma donation	10
Knowledge of plasma donation	6
No knowledge of plasma donation	4
Stem cell registration/donation
Registered stem cell donor	9
No experience with stem cell registration	1
Knowledge of stem cell donation	6
No knowledge of stem cell donation	4
Organ/tissue donation
No experience with organ/tissue donation	9
Knowledge of organ/tissue donation	5
No knowledge of organ/tissue donation	4
Not reported	1

Knowledge of community priorities and needs is relevant to understanding the broader sociocultural, political and community context. Key informants represented a range of community organisations including community/cultural, faith‐based, healthcare, and employment‐focused. Community priorities included healthcare disparities, gun violence, Islamophobia, and employment equity (see Table 3).

TABLE 3.

Community priorities.

Priority	Details
Healthcare disparities	Limited understanding of sickle cell disease, coupled with negative stereotypes of people who are ACB. For example, one participant spoke about instances where individuals seeking medical assistance for pain are unfairly labelled as drug seekers, reflecting a broader issue of systemic racism in healthcare.
	Healthcare challenges faced by adults with sickle cell disease in accessing specialised care.
	Insufficient funding dedicated to sickle cell programs in Canada compared to what they understand to be the substantial support received by similar programs in the United States. Lack of funding impacts treatment options, or lack thereof, follow‐up, and education for healthcare professionals about sickle cell disease.
	Disparities within maternal and child health and the lack of support for Black women. For example, the experiences of Black women who had difficulty during or post childbirth and whose pain was dismissed or were finding that healthcare professionals did not listen or address their concerns.
	ACB communities have been neglected and there is inequity in distribution of healthcare resources, as evidenced by their experience of the lack of family doctors in their communities leading to challenges in accessing primary care.
	Lack of race‐based data in healthcare services was raised as a priority and community concern. Without this data, it is difficult to know empirically the extent of health disparities for ACB communities and how to address these.
Gun violence	Gun violence primarily experienced by youth and young Black men at the hands of police and lack of action to address this.
Islamophobia	Addressing Islamophobia and its impact on the community, particularly in the context of the school system.
	Bill 21 in Quebec that prohibits all civil servants, including teachers, police officers, and public prosecutors from wearing religious symbols, including a hijab, while working, limiting employment options for people who wear a hijab.
Job security	Repercussions of immigration, financial stress, and impact of individual biases in hiring practices.
	Improving employment opportunities extended to the educational pipeline and the need to improve educational opportunities and representation in educational settings for ACB post‐secondary students.

3.2. Barriers to donation

All key informants viewed donation as a valued act, with four key informants having collaborated with a BCA to support donor recruitment. Still, all recognised that many in their communities face barriers to donation. Informed by our theoretical approach, in our results, we outline barriers that key informants described and consider them in relation to the broader community and sociocultural context. In some instances, we focus on one or two key informants that offer exemplary descriptive cases of a barrier. Key informant recommendations to BCAs on addressing barriers are included in Table 4.

TABLE 4.

Key informant recommendations to BCAs to address barriers to donation.

Barrier	Recommendations
Differing sociocultural views on donation	Staff to receive training in cultural competency and humility and ensure they do not respond with nonverbal cues (e.g., quizzical looks) that may read as signalling judgement when being asked questions about blood and donation from the perspective of different sociocultural views.
	Provide potential donors an opportunity to ask staff questions about their blood donation prior to deciding to donate, preferably in a private room.
	Increase the diversity of frontline staff so community members can see themselves represented in donor centres. This would also help send the message that donor staff are aware of cultural diversity and plurality of views.
	Provide clear and culturally competent information about the blood donation process, including what happens to donated blood and how it will be used.
Mistrusting BCAs	BCAs to develop meaningful relationships and collaborations with community organisations. Some specified that these collaborations had to move beyond one‐off social media partnerships between BCAs and community organisations and focus on longer‐term, authentic collaborations.
	BCAs to take the time needed to build trust and to work with Black healthcare leaders who are trusted by community members. This includes recognising and acknowledging that many ACB communities do not trust structures and organisations because of their experiences with systemic racism.
	BCAs should initiate outreach to ACB community leaders, such as leaders in churches, mosques, and community centres.
	BCAs should demonstrate allyship with community organisations and support organisations and groups advocating for donation rather than aiming to spearhead the campaigns themselves or asking organisations to follow their lead and campaigns.
Viewing deferral criteria as exclusionary	BCAs to acknowledge the effects of deferral criteria that disproportionately affect people from ACB communities
	BCAs should ease deferral criteria that disproportionately affect ACB communities while maintaining safety of the blood supply.
	Effective communication of deferral criteria by BCAs is needed to help address this barrier.

3.2.1. Mistrusting BCAs as an extension of healthcare systems

As key informants explained, trust in BCAs is critical for community members to overcome differences in sociocultural views on donation, to be reassured about what will happen to their donated blood, and to participate in donation. One key informant thought that ‘mistrust is the first reason’ (P07) why people in her community do not donate. From her perspective as someone in public health, she situated mistrust of BCAs under the broader umbrella of mistrust in science and medicine:

I think the more I went into public health, the more I realized the mistrust that there is between the Black community and anything that is scientific and medical, there is that, that we don't trust these people, so the idea to go and give blood, it's like, what are they going to do with our blood? (P07)

According to P07, mistrust in science and medicine is extended to mistrust in BCAs, suggesting that for some in ACB communities, negative experiences in research and healthcare informs mistrust of BCAs. P07 understood this mistrust in medicine and science to be informed by historic abuses including the Tuskegee Syphilis Trial in the United States, in which African American airmen were harmed by withholding antibiotic treatment so researchers could study the progression of syphilis. ²⁵

Given that mistrust in BCAs is informed by broader community, social, and healthcare contexts, it is necessary to consider these. For several key informants, a community priority was to address healthcare disparities including maternal and child health, and lack of healthcare services and options for adults living with sickle cell disease. Many described experiences of racism when seeking healthcare services including being labelled a ‘drug seeker’ when a Black person living with sickle cell presents at an emergency room during a pain crisis asking for pain medication. The broader healthcare context, then, is one in which many ACB people cannot trust that the healthcare system is there to provide them with the care they need; instead, they must approach with caution and be prepared to advocate for the care and services they require. These experiences, in turn, inform their expectations of and hesitation towards BCAs.

At least one key informant situated mistrust of BCAs in the context of structures beyond healthcare, such as education, explaining it this way:

So there is that scepticism and untrusting of the structure itself, and recognizing that I can be participating with this structure, but I cannot support the structure. And then donating blood is seen as supporting the structure. (P09)

For her, a community priority was advocating for equitable educational and employment opportunities for ACB people. She explained that as she and her community saw it, education, employment, and healthcare structures in Canada were not established to support them as evidenced by obstacles to access and lack of recognition of ACB people and their contributions and achievements. In the context of an inequitable structure, she distinguishes between participating in the structure, because it is the only structure that exists and necessary for the person, and supporting it by contributing to it. Here, BCAs are constructed as being part of the broader ‘structure’ that is not designed to support ACB people, and in this context, donating blood can be viewed as supporting or reinforcing this inequitable structure.

3.2.2. Navigating differing sociocultural views on blood and donation

All cultures, including Western North American culture, hold views on blood that inform donation practices. Barriers to donation may arise when people and communities hold sociocultural views that differ from dominant views underlying blood donation systems. The dominant Western view is that blood, once drawn from one person, is free of any meaningful ties to that person and becomes an object or ‘thing’ (e.g., a biologic) that can be transfused. This view is not shared across all other world views, nor is it necessarily the ‘right’ view. In this study, some key informants discussed the importance, meaning, and sacredness of blood for them and their communities. Because blood is meaningful and valuable, they are responsible for being good stewards of their blood, which includes knowing where it is going and who will receive it. As there is great heterogeneity across highly diverse ACB peoples and communities, these views should not be assumed to be held by all ACB people; however, they are significant to some.

Viewing blood as sacred was exemplified by one key informant, P05, who is first‐generation Canadian. She continues to be connected to her ethno‐cultural community both in Canada and abroad through her community leadership work. She described her and her community's views on blood, body parts, and the exchange of these parts as such:

I used to hold this belief as well, that, well I'm not going to give my blood for someone to keep somewhere, right? Because blood is meant to be, what we consider, sacred, we want to know where our blood is going, and I want to know, who's getting that blood… (P05)

Differing views do not in and of themselves represent a barrier to donation. However, if people who hold different views from the dominant one underlying the blood system are not able to satisfactorily express these views and ask questions, this can lead to constructing a barrier to donation. As P05 explained, if she and members of her community knew ‘where it's [blood] going, and I can trust that this is where it's going’ they would consider donating. Her trust in the BCA intersects with differing views on blood and donation whereby sufficient explanation by the BCA coupled with trust in their explanation could mitigate conditions that may otherwise become a barrier to donation.

Lastly, some key informants expressed how concerns of cultural judgement from BCA staff when raising questions related to differing views on blood contributed to difficulties in asking questions and receiving the needed information. Concerns with cultural judgement were related to what some viewed as a lack of ACB representation in donor centre staff and an overall lack of opportunity to ask questions to staff. These contributed to conditions that reinforce community members' lack of information about blood donation that key informants described.

3.2.3. Viewing deferral criteria as exclusionary

Key informants viewed donor deferral criteria that disproportionately affect ACB people as exclusionary and discriminatory and barriers to donation. Some viewed the current malaria deferral criterion in Canada that prohibits anyone with a history of malaria from donating whole blood as exclusionary because almost everyone they know from Africa has had malaria:

… that would mean, almost all of the population of African descent in Canada, I have had malaria, multiple times… it's almost as if there's a deliberate attempt, or, I don't know, deliberate attempt, let me just say it as it comes to me, deliberate attempt to exclude people of African descent, particularly Black people. (P05)

Another key informant described the screening criteria as one in which people in her community could see themselves ‘targeted in a policy or discriminated upon in a policy’ (P09), suggesting that when deferral criteria are considered to align with one's identity, the criteria may be experienced as an identity‐based deferral.

In addition to the malaria deferral criteria, key informants also referred to historic criteria that prohibited people from some countries in Africa from donating as an example of specific BCA practices that contribute to mistrust:

… it's hard for anyone to trust an organization that's historically, you know, discriminated against our communities. (P04)

P04 is a first‐generation Canadian and learned from others in her community that people from ‘certain countries in Africa are not allowed to donate’ (P04). Based on this, she has never attempted to donate blood despite the deferral criteria that restricted donations from African countries, related to HIV variants, having been lifted in 2018. ²⁶ Another key informant (P15) who had been a regular blood donor, recalled being permanently deferred in 2015 because she was dating someone who was born in an African country. Again, despite this deferral being lifted, she had not attempted to donate again. This speaks to the enduring social legacy and indirect function of deferral criteria. That is, when information about deferral criteria is shared among trusted community members this may keep people from even attempting to donate.

Other key informants, such as P03, had attempted to donate and experienced being deferred directly. She had volunteered at mobile blood drives held by her community in Quebec and when she attempted to donate was told that she could never donate blood because of where she was born and malaria risk:

I was talking with the lady [donor screening staff] who was taking the information and when she asked me, what country I came from, when I said, [African country], she stopped, she said, oh, you can't give blood. And I asked her why, she said, because in [African country] there is malaria. And any person who had malaria or their mother or their grandmother, live[d] in a country or even visit a country where there is malaria, cannot donate blood. So, I asked her, so when you say, grandmother, and mother, do you mean that even if my kids are born here, they cannot donate blood? She said, no, because you have been in a country with malaria. So, she said that my daughters will not be able to donate blood and not even their kids, when they grow up and have kids, and she told me to not even try to donate anymore. (P03)

P03 recalled being told that the lifetime deferral for malaria applied to multiple generations in her family and therefore did not talk about blood donation with her children or community members. She also stopped volunteering at blood donor drives since she found it difficult to support an organisation that had so clearly sent her the message that she is not wanted. What matters here is less the veracity of what she recalled (Canada has never had a multi‐generational deferral for malaria), and more the mis/information she received and the impact of this experience and its lasting effects on her, her family, and community.

4. DISCUSSION

Our analysis demonstrates how mistrusting BCAs as an extension of healthcare systems, differing sociocultural views on blood donation, and viewing deferral criteria as exclusionary become barriers to donation for some ACB people and communities. These results are consistent with findings from other studies in Canada and abroad, ¹³ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ and build on these findings by considering how these systemic barriers are constructed by the broader context. While findings might be consistent across jurisdictions, addressing these barriers requires a context‐specific approach that takes into account local social, political, and organisational considerations. Our analysis extends prior work by showing how screening criteria that defer people with a history of malaria is experienced as discriminatory and constructed as an identity‐based deferral for some ACB people in the Canadian context. Results from this study also extend our prior work with ACB young adults. In our previous study, while deferral criteria were identified as a barrier to donation, young adults had much less to say about the malaria deferral criteria than key informants in this study and several young adults spoke about the prior men‐who‐have‐sex‐with‐men deferral criteria. ¹³ This difference is likely related to community leaders being older than the young adult participants and more likely to be aware of and impacted by the malaria deferral criteria either directly or indirectly.

Permanent deferrals, such as the one for a history of malaria, have been found to generate feelings of confusion, fear, anger, and stigmatisation in donors ³⁴ ; however, by suggesting that the malaria deferral criteria are experienced as an identity‐based deferral moves beyond individual affective responses to considering how responses to deferral criteria may be related to understandings of identity and personhood. Here, we suggest that the concept of ‘bio‐identity’, or ‘our commonsense understanding of our bodies as “ours”, as both supporting and being included in our social and subjective identities’ is useful. ^{35 (p.1462)} The permanent deferral of people with a history of malaria may be viewed by some as a rejection not only of a person's blood, but by extension of the person themselves.

Currently in Canada, there is a permanent deferral from whole blood donation for anyone with a history of malaria. A Nucleic Acid Test (NAT) for malaria was licensed in 2025 in Canada and, following Health Canada regulatory approval, CBS aims to integrate this assay into mitigation strategies for malaria and remove the permanent deferral for whole blood donation for people with a history of malaria. ²⁶ Easing this deferral criterion is a positive step towards addressing a significant barrier to donation, and an action recommended by key informants. However, as our analysis shows, even with the removal of a permanent deferral, its legacy and impact on a community may remain. This suggests that changing deferral criteria to be less restrictive must be coupled with efforts to address other barriers, including trust building and offering culturally safe opportunities for ACB communities to discuss donation from within their cultural framework.

4.1. Limitations

This study focused on systemic barriers to donation and therefore we do not make any claims to have examined an exhaustive list of barriers, including barriers at the individual level (e.g., fear of needles). It is also worth noting that the English language eligibility requirement may have limited some people's ability to participate in this study; future research should facilitate participation from people in ACB communities who are less comfortable communicating in English. Moreover, while having all key informants identify as women is not necessarily a limitation of this study, for a more intersectional analysis with regard to gender and other social dimensions, future research studies should aim to hear from ACB community leaders of different genders. Further research that explores the relationships between individual‐level and systemic‐level barriers is needed. Lastly, additional research to understand the conditions and context that produce barriers from BCAs' perspectives is warranted to gain a more complete understanding and better reduce barriers.

5. CONCLUSION

BCAs make appeals to increase ACB donors while at the same time members of ACB communities are not able to donate because of deferral criteria and other systemic barriers. This reflects a ‘paradoxical situation’, as coined by Charbonneau and Tran. ³⁰ We suggest that BCAs can approach this paradoxical situation by looking to the recommendations made by key informants. These include partnering and collaborating with ACB community groups that are already advocating for blood donation and healthcare access more broadly. Despite the challenges to blood donation, several key informants had collaborated with BCAs and viewed their relationships as positive and effective. Where collaborations are sought, it is critical that BCAs approach these thoughtfully and enable community organisations to lead and guide the work as much as possible.

AUTHOR CONTRIBUTIONS

Jennie Haw: Conceptualisation; methodology; data collection; analysis; writing—original draft; writing—review and editing; project administration; funding acquisition. Joyeuse Senga: Analysis; writing—review and editing. Dzifa Dordunoo: Conceptualisation; methodology; data collection; analysis; writing—review and editing. Biba Tinga: Conceptualisation; methodology; analysis; writing—review and editing.

FUNDING INFORMATION

This research received funding support from Canadian Blood Services, funded by the federal government and the provincial and territorial ministries of health. The views herein do not necessarily reflect the views of Canadian Blood Services or the federal, provincial, or territorial governments of Canada.

CONFLICT OF INTEREST STATEMENT

The authors have no competing interests.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.