Investigation of the Reasons for the Non‐Return of Lapsed Blood Donors: A Qualitative Study

ABSTRACT

Background and Aims

Retaining and re‐engaging blood donors to ensure a safe and sufficient blood supply is a key responsibility of the Blood Transfusion Organization. This study aimed to investigate the reasons for the non‐return of lapsed blood donors to facilitate their re‐engagement.

Methods

This qualitative study, conducted in 2024, employed a conventional content analysis approach using four focused group discussions (FGDs) and individual interviews with seven lapsed blood donors selected purposefully. The credibility and reliability of the qualitative data were ensured through techniques such as maximum variation sampling, member checking, peer review, and the use of participant quotes. The interviews were recorded, manually coded, and categorized. Data analysis was carried out using Colaizzi's seven‐step method.

Results

In total, 34 individuals participated in this study. The reasons for non‐return included 94 initial codes, 26 subcategories, and 8 categories (medical and non‐medical health‐related reasons, life responsibilities, changes in attitude toward blood donation, blood donation with others, desire to perform wet cupping for ideological reasons and community recommendations, beliefs about blood donation, organizational limitations, and cultural awareness). These were grouped into three main themes: individual reasons, social determinants of blood donation, and social marketing of blood donation.

Conclusion

By understanding the individual needs of donors, community beliefs, and expectations, it is possible to promote a culture of blood donation through appropriate advertising and the production of up‐to‐date content in governmental and social media.

Summary

• Multiple barriers influence donor retention, including individual (health, attitudes, life responsibilities), social (peer influence, cultural beliefs), and organizational factors (logistical limitations). Implication: Targeted interventions must address this multidimensional nature to improve return rates.

• Cultural and ideological preferences (e.g., favoring wet cupping over blood donation) significantly impact donor behavior. Implication: Community engagement and education are needed to align donation campaigns with local values.

• Gaps in social marketing (awareness, institutional support) hinder sustained participation. Implication: Strengthening donor outreach programs and streamlining organizational processes could enhance retention.

1. Introduction

Blood donation is considered one of the most important and humanitarian voluntary activities, with the aim of saving lives [1]. Given the critical importance of this initiative, ensuring the safety of blood is of special significance [2, 3]. Retaining and re‐engaging of blood donors that are the lifeline of the blood supply chain, often poses significant challenges. Regular donors are particularly valuable, not only because they help maintain a steady supply but also because their blood is often safer than that of first‐time donors or individuals who have not donated in a long time. The rigorous screening and consistent monitoring of regular donors reduce the risk of transmissible infections [4]. Additionally, due to the sense of role and civic responsibility that these donors attribute to themselves, they exhibit lower‐risk behaviors compared to other groups, further emphasizing the importance of this issue [5]. While attracting new donors is very important, retaining regular donors is considered one of the key strategies for blood transfusion organizations. This group of individuals can act as supporters of the blood transfusion organization in critical situations, such as natural disasters or social catastrophes. Despite all the efforts made by the blood transfusion organization to attract and retain these donors, many donate blood only once and do not return for subsequent donations. According to available statistics in Iran, nearly 50 percent of those who have donated blood once showed no willingness to donate again [2]. Some regular blood donors who have been donating for several years have become lapsed donors who have not visited for blood donation in over a year. Therefore, identifying the reasons for the non‐return of these donors can help attract them back for blood donation and increase the motivation of first‐time donors to return [6]. Multiple studies have shown that various factors can influence the non‐return of donors. For instance, issues such as pain from the needle, dizziness, or fainting after blood donation, as well as unpleasant experiences with medical staff, can significantly affect individuals' decisions not to return [7]. A study conducted by Hasanzadeh and colleagues [8] in Iran revealed that one of the key factors affecting donor return is improper interactions and inappropriate behavior from medical staff towards them. In the other study showed that only 34.8% of individuals who were temporarily deferred from donating blood returned to donate again within the following 3 years [9]. These findings highlight the importance of donors' initial experiences with blood donation and their interactions with medical personnel. In a review study, barriers to willingness to donate again were examined. These barriers included a lack of time, fear of needle sticks, concerns about contracting viral diseases such as HIV, uncertainty about the sterility of equipment, lack of awareness regarding blood preparation, storage processes, and the use of donated blood for patients in need. Additionally, frequent blood donation has led to decreased iron reserves in some donors. Among female donors, doubts about donating blood in child‐bearing. ages and the fear of anemia had resulted in the cessation of blood donation [10]. Despite existing research, there are limited studies specifically addressing the reasons for the non‐return of lapsed blood donors in Iran. Most of these studies have focused on the psychological and physical factors related to the initial blood donation experience, rarely examining the experiences and obstacles faced by non‐return donors. This research gap exists despite the fact that a deeper understanding of the reasons behind the non‐return of donors can aid in improving the programs and strategies of blood transfusion organizations to retain this group. Additionally, investigating the reasons for non‐return among donors whose last visit was not due to deferral can serve as a guide for blood donation organizations in re‐engaging these blood donors. Therefore, the present study employs a qualitative approach to analyze the factors affecting the non‐return of lapsed donors in Iran. This approach has been chosen because it allows for a more detailed and comprehensive examination of donors' personal and social experiences. This qualitative study utilized in‐depth interviews and analytical methods to gain a deeper understanding of individuals' feelings, beliefs, and experiences [11] and is particularly effective in identifying the hidden and complex barriers that influence the decision‐making of lapsed donors. This study aimed to uncover the reasons for the non‐return of this group of donors by utilizing qualitative data and in‐depth analysis, as well as to provide strategies for improving the retention of these individuals.

2. Methodology

2.1. Study Type

To explore the reasons for the non‐return of lapsed blood donors, a qualitative research approach grounded in a naturalistic philosophical perspective was utilized. To gain a deeper understanding of the context in which these experiences occurred, a descriptive phenomenological approach was employed [12]. Phenomenology is a systematic and precise method aimed at discovering and revealing the perceptions of human experience regarding phenomena as they occur and as they manifest in our conscious reality [13].

2.2. Sampling

In this study, purposive sampling was employed [14]. The participants included individuals with a history of blood donation who reside in the province of Yazd, Iran and have not donated blood for at least 2 years. The inclusion criteria required that participants' last successful blood donation occurred more than 2 years ago and were within the eligible age range for blood donation. Therefore, lapsed donors under the age of 55 were selected for interviews. Exclusion criteria included individuals whose last visit was due to their deferral from donating blood. Additionally, efforts were made through phone calls to select participants who were interested in participating in the study [15]. Sampling continued until data saturation was achieved, meaning no new themes emerged [16].

2.3. Data Collection Tools

For this research, a focus group Discussion (FGD) methodology was used, which is considered one of the qualitative interview techniques that allows for an in‐depth exploration of various dimensions of a topic [17]. A focus group consists of a semi‐structured interview session led by a facilitator, taking place in an informal setting to gather information on a specific topic. A prominent feature of focus groups is the interaction among group members (interviewees), which fosters the exchange of opinions and ideas; this interaction may not easily occur in individual interview sessions. The formation of a focus group is not solely for problem‐solving or decision‐making; it is considered a type of interview session. Focus groups typically consist of 8–12 individuals who share specified relevant characteristics related to the topic of discussion, and the selection of members for these groups is primarily based on purposive sampling. In selecting individuals for the study, attention was given to choosing participants who were homogeneous yet possessed characteristics that enhanced the diversity of the research findings. Researchers utilized semi‐structured in‐depth individual interviews to gather specific viewpoints and enrich the data regarding the phenomenon under study. The interviews were conducted using a guide that included open‐ended questions regarding donation experiences, personal perceptions of the donation process, and potential barriers. The donors' information was collected from the blood transfusion organization. Participants were included if their last healthy blood donation was recorded more than 2 years ago. This 2‐year interval was chosen because, according to the Iranian Blood Transfusion Organization's definition, individuals who have not donated blood for over 2 years are considered “experienced donors,” a category relevant to our study on lapsed donors. An interview guide was designed to organize the discussion and included general and open questions related to blood donation experiences and reasons for non‐return visits. These questions were crafted to allow participants to discuss and exchange views freely. They included questions such as “What was your experience with your last blood donation?” and “In your opinion, what contributed to your non‐return?” These questions were asked in various sessions, and previous session questions were reviewed to enhance understanding of the concepts. A list of 250 donors was compiled from the donor information, which included their contact details and addresses. Using this list, potential participants were contacted, paying attention to the diversity of participants regarding gender, age, education, and place of residence. Four focus groups were conducted. Three groups consisted of male lapsed donors categorized by educational level (less than diploma, diploma to bachelor's degree, and bachelor's degree or higher). Because female donors constituted a small proportion of all donors (approximately 15%) and, due to cultural and religious considerations, mixed‐gender focus groups were not appropriate, eligible female lapsed donors were invited to a separate, single focus group. From this list, 19% accepted the invitation for an interview, and several of them attended the blood transfusion organization on the day of the invitation. Furthermore, semi‐structured individual interviews were conducted with 7 participants to enrich the information obtained. In total, 34 individuals participated in this study, consisting of 25 men and 9 women (Tables 1 and 2). Individual interviews were held in quiet locations, taking into account the comfort of the participants. Each session lasted between 60 and 78 min, and the interviews took place from January to February 2024 in the meeting hall of the blood transfusion organization. In these sessions, a facilitator, one of the experienced researchers working according to the semi‐structured interview guide, led the discussion. The average age of participants in the focus groups and individual interviews was 39 ± 5.3 years (range: 25–55 years) (see Tables 1 and 2).

Table 1.

Characteristics of participants in the focus group discussion (FGD).

Education	Sex	Participants	Duration (min)	FGD
Under Diploma	Men	8	62	1
Diploma to Bachelor's	Men	7	78	2
Master's Degree and Higher	Men	5	72	3
All‐Inclusive	Women	7	65	4

Table 2.

Characteristics of participants in the individual interviews.

Individual interviews	Age	Donation donation lapse period (months)	Sex	Education
1	54	26 months	Man	Under diploma
2	42	25 months	Man	PHD
3	47	35 months	Man	PHD
4	50	23 months	Man	Bachelor
5	38	25 months	Woman	Bachelor
6	52	34 months	Woman	Elementary
7	Man	28 months	Man	Diploma

2.4. Data Analysis

The collected data were analyzed using Inductive Content Analysis and the seven‐step method of Colaizzi [18]. This process involves describing the participants, extracting key phrases, conceptualizing the phrases, categorizing the concepts into thematic groups (subcategories), classifying them, and identifying the main themes from the results. Additionally, in this phase, an overall description of the phenomenon under investigation is prepared as a clear and concise statement. The data analysis began with the first interview, and the initial interview along with several subsequent interviews were discussed and deliberated with researchers with more experience in this field.

2.5. Trustworthiness

To guarantee the accuracy and reliability of the data, the criteria established by Guba and Lincoln were employed [19]. The researcher dedicated ample time to collecting and analyzing data, fostering a positive relationship with participants to enhance the credibility of the results. Data diversity was ensured by incorporating participants with varied demographic characteristics and different donation histories. Throughout the analysis, constant comparisons were conducted across transcripts, and iterative refinements of the codes were performed to preserve the authenticity of the data. Independent coding of the transcripts was carried out by two researchers, after which coding discrepancies were reviewed and resolved through consensus discussions. Dependability was strengthened by maintaining a comprehensive audit trail, in which all decisions related to code development, code modification, and category formation were systematically documented. Each phase of the content analysis—from initial open coding to the development of final themes—was recorded, and reflexive notes and analytic memos were kept to ensure transparency of the analytic process. Additionally, to bolster the confirmability of the findings, a summary of the researcher's insights from each interview was shared with participants at the end of each session, allowing for the validation of the researcher's interpretations. During the analysis and categorization of the data, some participants were shown the extracted categories and codes to gather their opinions on the accuracy of the labels and codes. To enhance the transferability of the findings, the culture, context, participant characteristics, data collection methods, and analysis techniques were thoroughly described. Moreover, the analyses were reviewed by several researchers to ensure the convergence of the data.

2.6. Ethical Considerations

Before conducting the interviews, the researchers provided participants with a clear explanation of the purpose of the invitation and the study's objectives. Upon arrival, participants were given an informed consent form to sign, ensuring they were aware of the study's details before agreeing to participate. Additionally, prior to each interview, the researcher offered a thorough explanation of the study at the beginning of the session and informed participants that they could withdraw from the interview at any time. To avoid losing important information, the interviews were recorded with the participant's consent, and these recordings would be deleted after the content analysis was completed. Participants were assured that the interview transcripts would remain anonymous, and at no point during the research would personal names or identifying information be disclosed. The primary goal of the study was to extract relevant concepts. This research was reviewed by the High Institute for Research and Education in Transfusion Medicine, Tehran, Iran, and was approved under the ethical code IR. TMI. REC.1403.001.

3. Results

The data analysis was organized into four main themes, which reflected the key points derived from the discussions and individual interviews. These themes were supported by 8 categories and 26 subcategories, which provide a more precise representation of the interpretations obtained.

The overall findings are presented in Table 3, based on interviews conducted in four thematic areas. The first refers to “individual reasons” why lapsed donors do not return to the blood centers for blood donation. The second area relates to the “competition between Wet cupping and blood donation,” which has led some individuals to refrain from donating blood, posing a significant challenge to the blood supply. The third theme concerns public beliefs that may diminish the motivation of lapsed donors to donate blood again. Social marketing is one of the primary themes associated with how to attract more donors continuously, and each of these main themes will be explained in detail.

Table 3.

Extracted themes, categories, subcategories, and main codes from qualitative interviews.

row	Code	Subcategory	Category	Main theme
1	Cancer	Reasons for Illness	Medical and Non‐Medical Health‐Related Reasons	Personal Reasons
2	Chemotherapy
3	Diagnosis of anemia by a doctor
4	Surgery (ovary)
5	Medication usage
6	Brain tumor
7	Favism
8	Rheumatism
9	Severe COVID‐19 and body weakness	Feeling of body weakness after contracting COVID‐19
10	Feeling weak and lethargic after COVID‐19
11	Feeling unwell after the last blood donation
12	Pregnancy (women)	Specific individual conditions
13	Breastfeeding (women)
14	Husband not attending (women)	Life responsibilities of women	Life responsibilities
15	Childcare
16	Child's illness
17	Unforeseen problems in life	Life challenges
18	Life issues
19	Lack of time
20	Relocation
21	COVID‐19 restrictions and absence	Interruption caused by COVID‐19	Change in attitude towards blood donation
22	Absence due to COVID‐19
23	Fear of COVID‐19
24	Replacing blood donation with other methods due to COVID‐19	Replacing with other methods
25	Leech therapy preventing blood donation
26	Blood donation habit no longer part of routine life	Decreased motivation
27	Decreased desire to donate blood after a break
28	Feeling that others will donate, and there's no need for me
29	Absence of friends for blood donation	*******	Blood donation accompanied by others
30	Absence of colleagues for blood donation
31	Blood donation when called by NGOs
32	Blood donation when called by volunteer groups
33	Continued visits for Wet cupping therapy	Turning towards Wet cupping therapy	Desire to perform wet cupping for ideological reasons and community recommendations	Social determinants of blood donation
34	Not visiting for blood donation due to Wet cupping therapy
35	Belief in the benefits of Wet cupping therapy compared to blood donation	Beliefs about the advantages of Wet cupping therapy over blood donation
36	Religious teachings related to the importance of Wet cupping therapy
37	Family belief in prioritizing Wet cupping therapy in normal circumstances
38	Friends' recommendation for Wet cupping therapy	Recommendations from acquaintances for Wet cupping therapy
39	Relatives' advice not to go to the blood transfusion center for donation during COVID‐19
40	Explanation of the advantages of Wet cupping therapy over blood donation by friends
41	Promotional behaviors of influential individuals, such as industry leaders
42	Clerical relatives' recommendation for Wet cupping therapy
43	Explanation of the advantages of Wet cupping therapy over blood donation by relatives
44	Explanation of the advantages of Wet cupping therapy over blood donation by female neighbors
45	Explanation of the advantages of Wet cupping therapy over blood donation by religious scholars	Recommendations from religious advocates and the community's religious culture
46	Greater attention of the people of Yazd to religious topics
47	Explanation of the advantages of Wet cupping therapy over blood donation by Wet cupping doctors	Recommendations from Wet cupping therapy doctors
48	Explanation of the advantages of Wet cupping therapy by other doctors inclined towards traditional practices
49	Belief in donating blood only in emergency situations	Belief in donating blood only in emergency situations	Opinions about blood donation
50	Family's belief in the urgency of blood donation
51	Belief in donating blood in emergencies based on blood type
52	Belief that Wet cupping therapy is more beneficial than blood donation	Misconceptions about blood donation
53	Belief that bloods donation is harmful
54	Belief in aging and body weakness
55	Blood donation is only for men	Women's beliefs about blood donation
56	Menstrual cycles and belief in anemia in women (women)
57	Persuasion by others about the restrictions on blood donation for women (women)
58	Restrictive laws regarding blood donation	Organizational regulations	Organizational limitations	Social marketing of blood donation
59	The blood transfusion organization's inactivity on holidays
60	Fewer restrictions for Wet cupping therapy and others by compared to blood donation	Simple regulations for Wet cupping therapy and other
61	Wet cupping therapy and others is performed by many people
62	There are many places in the community for Wet cupping therapy	Abundance of Wet cupping therapy centers
63	Wet cupping therapy has fewer time restrictions compared to the Blood Transfusion Organization
64	The scarcity of blood transfusion organizations in Yazd city and province	Organizational facilities
65	The lack of mobile teams in the city
66	Inadequate planning for the presence of mobile teams at specific times
67	Decreased quality of blood collection needles compared to before	Quality of equipment
68	Inappropriate behavior of staff towards blood donors who have undergone Wet cupping	Communication among staff
69	Appropriate treatment of donors to encourage their re‐engagement by the personnel
70	Not taking blood from the father and feeling upset
71	Low attention from the blood transfusion organization to the value of blood donation in society	Inadequate information dissemination	Cultural awareness
72	Presentation of the benefits of blood donation by the blood transfusion organization
73	Explanation of the importance of blood donation by the blood transfusion organization
74	Unclear blood donation process
75	Unclear blood supply chain to the donor
76	Rumors regarding the side effects of blood donation, such as a decrease in platelet count
77	Low attention from the blood transfusion organization to the value of blood donation in society
78	Low activity of the media regarding blood donation	Insufficient advertising
79	Uniform text messages related to blood donation
80	Messages do not have much impact
81	Lack of reminder messages
82	Lack of promotion for blood donation across all platforms (television, radio, billboards, social media)
83	Very weak advertising from the blood transfusion organization, even at the entrance
84	Blood donation information is only provided during emergencies
85	Lack of appropriate appreciation from the organization for donors (women)	Attention to donors' needs
86	Failure to follow up on the status of individuals with a history
87	Creating additional test panels alongside blood health tests
88	The blood transfusion organization limiting its support to just providing juice (for women)
89	No contact from the blood transfusion organization to provide test results and necessary counseling
90	Recognizing donors as ambassadors for donation (women)
91	Establishing a blood donation pass for each individual every 4 months	Valuation
92	Identical incentive measures in previous years
93	Lack of motivation for blood donation staff, such as employee of the month or annual awards
94	Promoting blood donation within organizations

3.1. Theme 1: Personal Reasons

One of the barriers to the return of lapsed blood donors is personal reasons. These reasons are divided into two categories: medical and non‐medical. They include factors such as health issues, life commitments, changes in the willingness to donate blood, and donating blood in a group with others (Table 3).

The following section presents the themes as bold headings, while the categories are italicized within the text. When necessary, quotes are included in italics to support the analysis using the participants' own words. Medical reasons are one of the significant factors contributing to the lack of return visits by lapsed blood donors. In group discussions and individual interviews, several participants highlighted this issue. Conditions such as autoimmune diseases, reduced iron reserves, and other illnesses like brain tumors have prevented donors from coming forward to donate blood.

One participant expressed: I used to visit the blood center two to three times a year and felt obligated to donate blood. Although I wanted to donate, I was unable to do so anymore due to a diagnosis of a brain tumor and related complications. (FGD1 Men‐P3).

One participant expressed: Donating blood was an annual habit for me, and I would visit the blood center every 3 months, thanks to a reminder I set for myself. Unfortunately, after undergoing tests and discovering a decrease in my iron levels, I was unable to donate blood anymore (FGD3 Men‐P4).

Many individuals cited feelings of fatigue and malaise as one of the reasons for not returning to donate blood, with most attributing this condition to having contracted COVID‐19. They acknowledged that after the pandemic, they felt their bodies were not as healthy as before, leading to hesitation regarding blood donation. One of the subcategories related to reasons for not returning is the individual's specific condition. This pertains to women who had previously visited the blood center but are now unable to donate due to reasons such as pregnancy or breastfeeding. Life responsibilities were one of the categories associated with the theme of individual reasons, further divided into two subcategories: life commitments and women's responsibilities. Many individuals in FGDs have identified life responsibilities as significant reasons for not returning to donate blood. They mentioned reasons including lack of time, life crises, and increased responsibilities and workload.

One of the participants expressed: In the past, I truly had more free time and thought more about these issues. But now, I don't know what has happened; I feel tired and have a lot of work. Naturally, this causes the topic to come to mind less frequently or for me to pay less attention to it. (FGD3 Men‐P5).

Another reason for not returning to donate blood was referred to as life responsibilities, which pertained to lapsed women. This group of donors has found it challenging to visit due to reasons such as taking care of children, supporting family members, and various life commitments.

The following quote highlights this issue: I used to have more freedom and more time for myself. Unfortunately, my son has fallen ill, and I have to take care of him at home all the time (36‐year‐old woman, individual interview, bachelor's degree).

It has become difficult for me to go to the blood donation organization because my life has gotten busier, and I don't have enough time. If I want to go there, my husband must accompany me, but he is seldom home. (FGD4 women‐P1).

Another individual reason for the change in the willingness to donate blood included three subcategories: the interruption caused by COVID‐19, the adoption of alternative methods, and a decrease in motivation, all of which are linked to the pandemic. As participants mentioned, with the outbreak of COVID‐19 and the implementation of protective measures such as social distancing and reduced movement in crowded areas, the rate of blood donation decreased during this period. This interruption led to several consequences in the city of Yazd. Some individuals who were accustomed to donating blood turned to practices such as leech therapy (a traditional medicinal practice that uses leeches to draw blood, believed by some to have therapeutic benefits) and wet cupping (as Hijama, a traditional therapy where heated cups are placed on the skin, and a small incision is made to draw blood, also thought to have health advantages). These alternative methods increased their inclination towards them. Additionally, the rules and guidelines imposed by the Blood Transfusion Organization exacerbated the issue.

One of the participants expressed: I used to donate blood regularly, but with the outbreak of COVID‐19, fear of not contracting the virus in crowded areas, I had to do Wet cupping. After a few sessions, knowing that I couldn't donate blood after Wet cupping, I stopped going for blood donation. (FGD2 Men‐P4).

Additionally, due to the interruption caused by COVID‐19, several other participants also reported a decrease in their willingness to donate blood.

Before the COVID‐19 epidemic, I donated blood regularly, and it had become one of my habits. However, after I couldn't go to the blood donation center, this habit gradually diminished, and I stopped going (FGD3 Men‐P1).

The interruption that occurred after COVID‐19 decreased my motivation to donate blood and diminished my sense of importance and value. I tell myself that others are donating blood and that my blood is not needed as much (FGD1 Men‐P5).

Another reason for the lack of return visits for blood donation was the tendency to donate blood with others. Several interviewees mentioned that they usually went to donate blood alongside someone else, such as colleagues, friends, or family members. Thus, with the reduced willingness of their friends or colleagues, they also stopped going. Additionally, the lack of messages from NGOs or other groups regarding the need for blood donation has contributed to their absence. One participant expressed this issue as follows:

“I am one of the donors who goes to donate blood whenever I am able, but it has been a while since the group related to the leukemia kids has sent out a message about the need for blood donation, but it has been a while since they issued a recall” (FGD3 Men‐P2).

3.2. Theme 2: Social Determinants of Blood Donation

The social determinants of blood donation are categorized into two main groups [1]: The inclination toward wet cupping due to religious beliefs and recommendations from society, and [2]: opinions about blood donation.

In recent years, the discussion of traditional medicine and topics related to Wet cupping and other religious and traditional methods has become increasingly common, positioning it in competition with blood donation. Blood donation requires a series of essential procedures, and if donors undergo procedures such as Wet cupping, Medication use, tattooing, surgery, etc., they will be temporarily deferred from donating blood. This section discusses the reasons for the community's greater inclination toward Wet cupping. Reasons include a preference for Wet cupping over blood donation, recommendations from unqualified individuals, advice from Wet cupping practitioners, and easier access to Wet cupping centers or places. Individuals have turned to Wet cupping at the suggestion of friends or relatives, and this practice has become a habit for them. Additionally, the belief in the benefits of Wet cupping over blood donation from a religious perspective has also contributed to the greater preference for Wet cupping. One participant in FGD2 commented on this issue as follows:

Religious hadiths emphasize the importance of Wet cupping, and in Islam, the Prophet has recommended it (male, 47 years old).

In my family, Wet cupping is considered important, and for this reason, I have also engaged in Wet cupping, which has led me to stop donating blood (FGD1 Men‐P7).

Recommendations from unqualified individuals have also contributed to the community's attraction to Wet cupping. This section is divided into two subcategories: recommendations from acquaintances for Wet cupping and recommendations from religious propagators and the religious culture of the community. Suggestions from unqualified individuals, such as friends, colleagues, and relatives, have encouraged them to engage in Wet cupping. Additionally, the increase in religious and traditional discussions by colleagues, relatives, and religious propagators, along with their encouragement for Wet cupping, has further strengthened this trend.

One of our relatives is a religious student who has explained the importance of Wet cupping in our family. For this reason, several members of my family have undergone Wet cupping. Therefore, I was also encouraged to try Wet cupping (FGD1 Men‐P3).

The recommendations of Wet cupping practitioners are also one of the reasons for the competition between Wet cupping and blood donation. Many people consult Wet cupping practitioners as well as specialists in Iranian medicine. As a result, their inclination toward Wet cupping has increased. Additionally, easy access to Wet cupping services is another competitive advantage of Wet cupping over blood donation. Wet cupping is performed in many areas of the city, including private clinics, offices, and even at home by various individuals. Several participants in group discussions mentioned this topic. For example, one participant stated: “Wet cupping is like a dairy shop that exists in every neighborhood of the city. It doesn't have any days off on Fridays or Saturdays. You just need to call ahead or go in person.” (FGD1 Men‐P3). Opinions about blood donation refer to the convictions and attitudes that can hinder continuous blood donation. This category includes three subcategories: belief in donating blood during emergencies, misconceptions about blood donation, and women's beliefs about blood donation. The belief in donating blood during emergencies was one of the topics raised by some participants. They considered blood donation necessary only at times when relevant organizations announced it, and thus did not believe in donating blood regularly. One of the participants expressed this view as follows: I think that blood donation should be done when there is a need, and it's not always necessary. For example, in cases like a bus accident or severe bleeding where there is a real need for blood, it should be done. (FGD2 Men‐P5).

My blood type is O negative, so whenever there is an urgent need, and they call me, I will come to donate blood. (FGD3 Men‐P2).

I believe that I should come to donate blood whenever there is an announcement of a blood shortage. That's why I don't come to donate blood very often. (Individual interview, 52‐year‐old man).

Misconceptions about blood donation are another barrier to continuous blood donation. Some people believe that donating blood is harmful, while others think that, due to aging and weakening of the body, they are no longer able to donate blood. For example, one participant said, “I always used to go. I'm 45 years old now, and I think my body can't handle donating blood anymore; I feel weak, so I haven't gone” (FGD2 Men‐P4).

Additionally, beliefs such as the superiority of Wet cupping over blood donation have become widespread among people. Specific beliefs held by women regarding blood donation can also prevent them from returning to donate. Some women believe that blood donation should only be performed by men or that they are prone to anemia due to their monthly cycles. Several women mentioned this in group discussions: “Neighbors and my parents say that donating blood is for men. Repeating this notion has prevented me from returning” (FGD4 Women‐P6).

Another woman stated, “Everyone knows that women are prone to anemia due to their gender status, and even though I was interested in donating blood, my motivation for doing so decreased” (FGD4 Women‐P4).

3.3. Theme 3: Social Marketing of Blood Donation

Blood donation marketing consists of two main categories [1]: organizational limitation and [2] the development of a culture of blood donation. Organizational limitations can be further divided into subcategories including organizational regulations, Simple regulations for Wet cupping therapy and other, Abundance of Wet cupping therapy centers, organizational facilities, quality of equipment, and staff communication. One of the reasons for the lack of re‐engagement of lapsed donors is organizational regulations. Restrictive regulations regarding blood donation conditions can prevent lapsed donors from visiting the blood transfusion organization to donate blood. Factors such as antibiotic use, Wet cupping, tattoos, surgeries, and other reasons can create limitations or discourage individuals from returning for donation. Therefore, given that experienced donors are aware of these factors, they may refrain from visiting the organization and instead opt for alternative bloodletting methods. Additionally, the opening hours of the blood centers, which are restricted to specific times, may not coincide with individuals' available free time. This issue was mentioned by several participants across focus groups 1, 2, 3, and 4.

The blood transfusion organization is closed on Fridays, and I often cannot attend in the evenings. Additionally, the organizational facilities, such as blood centers, are limited in number within the city and are usually located far from my residence. Mobile teams are also significantly less active. According to some participants, the quality of blood collection equipment, such as needles, has reportedly decreased compared to previous years. The needles used for blood collection are not the same as before; they cause more discomfort, leading me to reconsider returning for future donations. (FGD4 women – P1)

Staff communication is also one of the issues that several participants mentioned. For example, one of the participants in FGD 2 stated: “I came to donate blood with my father. My father was deferred from donating blood. I was upset and felt bad. This incident reduced my desire to donate blood.” (Male, 36 years old, diploma).

Additionally, some individuals visited with friends and asked the staff about possibly performing Wet cupping before completing their application. They were dissatisfied with the staff's response, which diminished their motivation to donate blood.

One of the donors said: “I came to donate blood with my friend. Initially, I asked if I could donate blood since I had done Wet cupping. The staff responded sharply, saying no, you should not donate blood. They treated me disrespectfully in terms of both appearance and words. I was upset by this behavior.” (FGD3 Men‐P1).

The organizational culture is divided into subcategories: inadequate information, insufficient advertising, attention to the needs of donors, and valuing donations. Inadequate information is an issue that requires attention. Many participants did not fully understand the importance of blood donation. For instance, they were unaware of the usage and effectiveness of donated blood. One participant stated: “I want to know what use was made of the blood I donated, for what disease, and when it was used. Understanding these aspects helps me appreciate the importance of donating blood.” (FGD1 Men‐P2).

I'm worried that there might not be a need for my blood, and it may have been discarded. It would be helpful if they could provide information about the usage process. (FGD4 Women‐P2).

It's crucial for me to understand how much blood is donated and how it is utilized. Is it genuinely being used? (Individual interview, 28‐year‐old woman).

Insufficient advertising is also one of the barriers to blood donation growth in society, which several participants emphasized. They expressed dissatisfaction with the lack of significant actions from the Blood Transfusion Organization. Some participants pointed out that the organization's signage has faded and considered this an important issue. They mentioned that they hadn't seen billboards related to blood donation in the community or claimed to be unaware of them.

One participant stated, “Look, the Jihad University Organization advertises daily for classes throughout the city, but the Blood Transfusion Organization is passive.” (FGD3 Men‐P5).

In the national or provincial news media, there is also less attention to blood donation, and only during specific or critical times is there weak communication. It's very important for me that there be more activity in the media and social media regarding the importance of blood donation, the blood usage chain, and the reasons for blood donation, which are not being seen. (FGD3 Men‐P6).

Some participants described attracting donors as uniform and monotonous. Text messages that say “your blood is needed” are sent every 3 months, which no longer appeals to me and does not motivate me to donate blood. (FGD2 Men‐P2).

Attention to the needs of donors is also one of the subcategories of developing a culture of blood donation. Issues like the organization's reliance on giving juice, lack of follow‐up calls, inquiries about missed donations, communicating test results, showing special respect to these individuals, and conducting additional tests are needs that lapsed donors mentioned.

One participant described the issue in the following way: “I came for an interview today because I saw that a call was made from the organization. Many would like to be contacted and asked why they haven't visited.” (FGD4 Women‐P2).

When I visit the blood centers, they serve juice after blood donation without any changes or additional appealing options considered. (FGD1 Men‐P7‐P3).

Valuing donors is one of the topics that lapsed donors pointed out. They said, “Myself and several others would like to be valued in society. For example, having a ‘donor of the month’ recognition, congratulating blood donors, or providing paid time off for blood donation. These factors could significantly boost interest in donating blood and make it more appealing.”

One participant stated, “If I could receive a paid time off or a special mission for donating blood as an employee, I would certainly visit more often and feel good.” (FGD3 Men‐P6).

There should be a distinction made for individuals who come to donate blood so that they can better understand the importance of this issue. For example, they could be provided with administrative passes or allowed to use office vehicles to travel to the blood centers rather than limiting this to just Blood Donation Day. (Individual interview, 45‐year‐old man, PhD).

Additionally, women mentioned that female donors should be selected as ambassadors for blood donation and recognized, which could help expand the culture of blood donation among women.

4. Discussion

This study aimed to investigate the reasons for the non‐return of lapsed donors and utilized qualitative research methods. The results of this research identified three main themes, eight categories, and 26 subcategories. Personal reasons were one of the issues mentioned by several participants in each FGD and a few individual interviews. One reason for non‐return was medical and non‐medical issues related to personal health. These reasons included the onset of serious or chronic illnesses and the feeling of weakness after recovering from COVID‐19. The blood transfusion organization categorizes individuals into two groups—permanently deferred or temporarily deferred from donating blood—based on their health status. For instance, individuals diagnosed with hepatitis C, HIV, or other diseases are considered permanently deferred from donating blood. Similarly, if a person is taking a specific medication or has undergone surgery, they are temporarily deferred from donating blood for a certain period [20]. Some participants mentioned anemia as one of the factors contributing to their failure to return to blood donation. Studies have shown that frequent blood donation can reduce blood iron levels [22]. Therefore, paying attention to this group of donors by implementing recommendations such as conducting additional blood tests during screening can help prevent the progression of this condition [20]. Another reason for not returning to blood donation was related to feelings of weakness in the body and the belief that the body becomes weaker after COVID‐19. In a study examining the long‐term effects on donors who had contracted COVID‐19, 11% of participants reported feeling fatigued [21]. Nonetheless, contact with lapsed donors and providing them with medical advice are expected to be helpful. Life distractions are one of the topics addressed in this study, focusing on issues such as lack of time, heavy workloads, and responsibilities like caring for children and other family members. Lack of time is a keyword mentioned in other studies as a barrier to blood donation [10, 22, 23]. Furthermore, considering their life responsibilities, women need support from their spouses to attend blood donation centers. Other studies have also indicated that the lack of alignment and support from spouses can hinder repeated blood donation, which aligns with the findings of the recent study [23]. Breastfeeding and pregnancy are reasons for not returning to donate blood, which can reduce the number of regular female donors, as noted in other studies [10]. A change in blood donation habits was one of the factors that hindered regular donations. One of the significant reasons for this change was the COVID‐19 pandemic. The pandemic caused people to donate blood less frequently due to the restrictions at that time, and according to studies, blood donations decreased by up to 26% [24, 25]. As a result, some individuals have turned to alternative methods like Wet cupping. There has been an increasing trend towards traditional and complementary ways, such as Wet cupping, leech therapy, herbal medicine, etc. The interest in complementary therapies has also grown among patients with diabetes, cancer, and other diseases for treatment purposes [26, 27, 28]. Studies have shown that not performing a habitual behavior over time can gradually reduce the desire to engage in that behavior. Therefore, during the COVID period, the lack of blood donation may lead to a decreased inclination toward donating blood [29]. Another identified theme is the competition between Wet cupping (Wet cupping) and blood donation. Some interviewees believed that the benefits of Wet cupping are greater than those of blood donation. Additionally, given the significance of the Islamic faith in Iran, particularly in the city of Yazd, religious beliefs hold a high status. Thus, following religious sayings and recommendations is highly prevalent. As a result, religious recommendations and advice from others have increased the preference for Wet cupping [30]. Wet cupping is recommended by traditional healers for treating several conditions, such as headaches, back pain, high blood pressure, arthritis, etc [31]. Performing Wet cupping or other alternative methods can delay blood donation and, over time, reduce the frequency of blood donation among these individuals [32]. Social pressures from friends, relatives, and others can influence an individual's willingness or reluctance to engage in a behavior. Therefore, paying attention to social norms can play a significant role in blood donation. Previous studies have also confirmed the impact of abstract norms on the intention to perform a behavior [33, 34]. Additionally, easier access to places offering Wet cupping therapy may present competition for blood donation centers provided by the Blood Transfusion Organization. Due to the spatial and temporal limitations of blood donation centers compared to Wet cupping facilities, blood donation is less accessible. As a result, people in the community more easily turn to Wet cupping. Limited accessibility is one of the main barriers to consistent blood donation, as noted in other studies [23, 24]. Public beliefs can also be obstacles to regular blood donation. Common beliefs include that blood donation is only necessary in emergencies, the idea that only men should donate blood, and the perception that blood donation is harmful [35]. Therefore, raising public awareness about the importance of blood donation and reducing misinformation can increase the community's willingness to donate blood. Social marketing aimed at encouraging regular donations and attracting new donors is crucial. A lack of awareness regarding the importance of blood donation, the blood supply chain, and the significance of healthy blood may hinder the development of a blood donation culture in society [10, 36]. When people, especially donors, understand the blood donation process and the blood usage chain, they can share their knowledge with others, which may motivate themselves and others to donate again. The activities of the blood transfusion organization have mainly involved sending text messages. While text messages can initially encourage donors to return, their impact diminishes. Some participants noted that repetitive and monotonous messages did not increase their motivation to donate blood. Therefore, employing more diverse communication strategies and enhancing the visibility of the blood transfusion organization through national and local media can raise public awareness about the organizational mission. Additionally, by understanding common misconceptions and beliefs, the organization can provide accurate and helpful information to the public. In today's world, where mass media and especially social media platforms are highly active, people are exposed to vast amounts of information, making it challenging to distinguish between credible and false information [37]. Utilizing social media's potential to raise awareness about blood donation and analyzing content changes over time is essential for identifying key topics and strategically managing blood donors [35].

Additionally, listening to the opinions and expectations of donors can help re‐engage them. Implementing suggestions such as issuing incentive cards for staff, holding appreciation sessions for regular donors, and following up with donors who used to donate regularly can effectively attract lapsed donors. In the field of blood donation, social marketing holds significant importance, as attracting and retaining donors is one of the most effective strategies for ensuring a sustainable supply of safe blood. Blood centers and blood banks are increasingly aware of the importance and outcomes of social marketing in attracting donors and fostering loyalty to ensure regular donations. Therefore, analyzing donors and understanding their perspectives through social marketing is very important [38]. Utilizing strategies such as blood donation ambassadors from donors, considering their feedback in audience engagement, identifying competing products in the community like Wet cupping, and creating appropriate content can be effective in attracting new donors and retaining current ones. The role of employees and organizational communication can influence the attraction or repulsion of donors. Therefore, enhancing communication skills among staff can ultimately contribute to valuing blood donation within the community [39, 40]. One important factor influencing the improvement of blood donor reservoirs is communication [33]. Therefore, managers and policymakers in blood transfusion organizations should prioritize two‐way communication between donors and staff to enhance overall donor supply.

5. Limitations and Strengths

In this study, efforts were made to collect the opinions of lapsed donors using two methods: focused group discussions and individual interviews. However, several individuals did not attend the interviews, which were addressed by conducting personal interviews. One of the strengths of this study was its identification of important themes, such as the competition between Wet cupping therapy and blood donation. Given the current circumstances, there is considerable advertising by both doctors and ordinary members of society regarding the benefits of Wet cupping, which can serve as a significant warning for blood transfusion organizations. To increase blood safety, donors who undergo wet cupping are temporarily deferred from blood donation, which can discourage them from donating blood again. Another strength of this study is the use of two research approaches, FGD and individual interviews, which cover the limitations of both data collection methods.

6. Conclusion

The results of this study highlight the importance of understanding participants' opinions in organizational planning. Based on the findings, regular monitoring of donors, identifying barriers, and facilitating the blood donation process can reintegrate lapsed donors into the continuous donor cycle. Moreover, increased efforts by blood transfusion organizations both in national and local media, along with the use of social marketing tools, can significantly improve the perception of blood donation in society.

Author Contributions

Hayedeh Javadzadeh Shahshahani: supervision, methodology. Mojtaba Fattahi Ardakani: conceptualization, investigation, writing – original draft, writing – review and editing, resources. Farahnaz Amiri: project administration. Sadegh Kazemi: conceptualization. Sara Heydari: conceptualization, methodology. Moradali Zareipour: conceptualization. Seied Mohamadreza Aghaee Meybody: conceptualization, project administration. Hossein rointan: conceptualization, project administration. Mahatab Vaziri: conceptualization, project administration.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead/Corresponding author (Mojtaba Fattahi Ardakani) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.