Introduction

Since the first successful organ transplant in 1954, thousands of lives have been saved.1,2 However, the global demand continues to vastly outpace supply, where 157,553 solid organ transplants were performed globally in 2022 alone, but this only met less than 10% of the estimated need.3 The severity of this deficit is further underscored by recent data from the United States, where in July 2025, more than 10 individuals died each day while awaiting a suitable organ, and approximately 105,000 candidates remained on the national transplant waiting list.4 This gap arises not only from economic and medical infrastructural limitations, but also from low donor availability.5,6 Barriers such as limited awareness, ethical uncertainty, religious misconceptions, and fear of medical procedures have hindered public participation in organ donation.7

In KSA, organ transplantation began with the first living donation in 1979 and the formalization of organ donation after death (ODAD) in 1985. The Saudi Center for Organ Transplantation (SCOT) was subsequently inaugurated in 1993 and a period of unprecedented transformation has recently started.8,9 Driven by the ambitious healthcare reforms of Saudi Vision 2030, the SCOT coordinating efforts have achieved progress in living donor transplantation, positioning the Kingdom third globally with a rate of 45.49 per million population.9, 10, 11 By 2023, over 200 individuals had received the prestigious King Abdulaziz Medal for exceptional contributions to organ donation.12 However, understanding the true magnitude of these recent national advances requires a clear view of the pre-reform landscape.

Despite these successes and institutional efforts, deceased donor registration within KSA's opt-in system remains critically low, averaging just 3.31 per million population.10 Operationally, the national framework requires next-of-kin approval before any procurement procedure can take place. Historical utilization of reported deceased donor cases is inefficient, and a regional report indicated that only 6% of reported cases were utilized, with family refusal rates between 1986 and 2022 estimated at a staggering 67%.13 This persistent challenge highlights a significant disparity between the actual act and public acceptance of donation.

Public engagement with organ donation in KSA is on the rise. Historical and recent national and urban surveys have generally reported high acceptance rates (74% to over 87%),14, 15, 16, 17, 18, 19, 20, 21 and a strong willingness to donate (up to 77.7%).14, 15, 16,22,23 Studies among healthcare professionals indicate similarly high acceptance (up to 85%) and willingness rates (up to 92%).24, 25, 26 By contrast, peripheral regions exhibit lower engagement, with acceptance sometimes as low as 42%27, 28, 29 and willingness dropping to 30.3%.30,31 Despite these promising figures, formal registration historically remains critically low, where donor card possession is typically below 6%, with rates as low as 1.4% reported in regions such as Qassim. Even among medical professionals, the registration rate of 33.6% reflects a persistent “willingness-to-commitment” gap that was embedded in the community prior to modern interventions, and necessitates further investigation.21,25, 26, 27,32,33

Frameworks such as the Health Belief Model (HBM), Theory of Reasoned Action (TRA), and Theory of Planned Behavior (TPB) are widely used to categorize the factors that shape organ donation behaviors. In particular, the HBM evaluates decisions by weighing perceived benefits against barriers, such as religious misconceptions or procedural fears. In addition, the TRA and TPB emphasize the influences of subjective norms (e.g., family acceptance) and perceived behavioral control (e.g., accessibility of registration).

KSA is continuing to modernize its healthcare infrastructure under the Vision 2030 framework, and evaluating the progress of these reforms requires a historical benchmark. Hence, this study applied a national data set from 2017 to establish a pre-reform baseline and identify the socioeconomic factors and psychological barriers that predict or prevent ODAD awareness, support, and card possession among individuals.