Negotiating safety and inclusivity: a qualitative analysis examining public priorities for sexual behaviour screening in blood donation in Australia

Blood donor eligibility criteria require regular revision to ensure they are evidence-based and do not unnecessarily exclude population groups. In response to concerns about non-inclusive practices, some countries have replaced population-based sexual behaviour screening questions with gender-neutral (GN) alternatives. Any new questions must be informed by local evidence and be acceptable to donors and the public in that location. Drawing on frameworks of donation as citizenship and institutional trust, this qualitative study investigated perspectives on three different approaches to sexual behaviour screening questions among donors and the Australian public. We conducted structured interviews with 23 donors and 20 non-donors in Australia. Participants were purposively sampled to maximise diversity in age, gender, sexuality and ethnicity. Interview transcripts were analysed using inductive and deductive thematic analysis. Over half of participants indicated a preference for GN questions over the current approach and two non-GN alternatives. Through thematic analysis four themes underpinning their preferences were constructed: The principle of blood safety; understanding the impact of change and perceptions of safety; operational simplicity; and importance of inclusivity. While participants broadly assumed that more questions would yield greater safety, GN questions were valued as simpler and more inclusive. Notably, most participants were unsure of the implications of each approach for blood safety and eligibility – yet this did not undermine their support. Instead, acceptability was grounded in trust in the blood collection agency as a competent and legitimate institution capable of balancing competing priorities. Findings illuminate how the lay public navigate tension between safety and inclusion in health governance, delegating authority to trusted institutions rather than engaging directly with technical evidence. Donors and the public support GN screening in Australia, but that support is conditional on institutional trustworthiness rather than policy comprehension. This has implications for how blood collection agencies communicate policy change and for broader debates about inclusion, risk governance, and citizenship in health systems.