Discussion

This study demonstrated high public awareness and support (82.1%) for organ donation in KSA. Key demographics (women, postgraduates, and employees) had positive attitudes, but religious concerns and personal feelings were reported as barriers by the non-supporting minority. Crucially, despite this acceptance rate, actual commitment remains critically low, with only 5.6% carrying a donor card. This significant discrepancy between intent and behavior potentially indicates a classic “intention–behavior gap,” where high motivation fails to manifest as formal commitment due to limited “perceived behavioral control” and procedural friction.

Awareness, acceptance, and predictors

The high rate of support suggests the presence of strong “subjective norms” consistent with recent nationwide studies (87.4% in 2019 and 87% in 2023),14,17 suggesting that public health campaigns have established subjective norms that endorse organ donation as a pro-social behavior.

Female participants consistently exhibited higher awareness across all outcomes. This engagement aligns with current findings in Bisha and Al-Qassim,27,28 and may stem from women's traditional life-giving and caregiving roles, which could explain this altruistic health behavior.34,35 However, the translation of this awareness into practice is still mediated by the pivotal role of male consent in family decision making, necessitating tailored, culturally endorsed messaging to address their specific concerns.

Educational attainment, particularly at the postgraduate level, and active employment were strongly associated with ODAD awareness and support, consistent with established Saudi trends.17,27,30 Employment often reflects these educational advantages, so this socioeconomic group represents the demographic that is most likely to support donation and possess donor cards. The supportive majority reported high perceived benefits, whereas the hesitant minority had a distinct cognitive profile. A comprehensive analysis of the Saudi landscape necessitates examining the contrasting hesitant minority, whose opposition is primarily rooted in socio-cultural, emotional, and theological concerns.

Barriers to positive perception

Among the non-supportive minority, religious uncertainty, emotional fears, and concerns regarding bodily integrity were the primary barriers to ODAD acceptance. These concerns had distinct gendered patterns, necessitating segmented messaging. Within the HBM framework, these factors function as formidable perceived barriers that outweigh the perceived benefits of donation, signaling a shift toward belief-restructuring interventions rather than traditional awareness campaigns. The present analysis quantified the prevalence of these obstacles but the data set lacked the granularity required to interpret the underlying drivers. Thus, these findings may serve as a baseline for future qualitative research to investigate these complexities and inform more targeted interventions.

Commitment and card possession

Despite a solid foundation of support, the observed registration rate of 5.6% aligns with regional data from 2016 in Jeddah (4.6%) and Almadinah Almunawwarah (2.7%).21,33 Some recent national reports cite higher registration figures ranging from 17.8% to 21% in the general population17,36 and reaching 33.6% among healthcare professionals,26 but these figures still contradict another recent finding of a registration rate of 5.4% in 2023, which indicates a profound intention–behavior gap. In our cohort, almost 93% of those supporting ODAD failed to declare card possession, echoing previous findings where 84–98% of those supporting or willing to donate participants failed to formalize their commitment.21,27,32,33 The present study did not qualitatively evaluate specific motives for non-registration, but this disparity could be explained by systemic and logistical obstacles. For instance, data from Al-Kharj indicate that 97% of participants were unaware of the registration process despite their support.37 Other reports list ambiguity regarding registration procedures, concerns over organ misuse, or misconceptions regarding brain death.19,26 These obstacles diminish perceived behavioral control, making the act of registration feel inaccessible. Ultimately, the conversion of supportive intent into official registration represents a challenge for the Saudi transplantation community.

Insights into demographic variations in ODAD card possession provide a clearer understanding of the drivers of potential conversion. Female gender, postgraduate education, and active employment were associated with an increase of at least 1.8-fold in the likelihood of possessing an ODAD card. This suggests that educational attainment is closely linked to health literacy and the capacity for institutional navigation, which are both key drivers of translating attitudes into action. Building on these demographic associations, professional environments emerge as high-yield avenues for advancing organ donor registration.

Workplaces are ideal settings for general health promotion38 and vital for organ donor initiatives. High-intensity campaigns and integrating media with interpersonal communication have consistently led to substantial increases in employee registration rates.39,40 In particular, the use of “message immediacy”41 and perceived workplace support42 can amplify campaign impacts. International successes often rely on “opt-out” systems, but a modified approach for the Saudi context could involve an “active-choice” model. Studies suggest that by optimizing the choice architecture within these professional environments, the supportive population can be prompted to complete registration at the point of employment. Thus, maintaining a clear, perpetual option to opt out acts as a behavioral nudge that bypasses procedural and cognitive friction to bridge the intent–action gap.

Our findings and those obtained in other studies highlight the substantial progress made in improving public awareness and positive attitudes toward organ donation in KSA. The primary challenge is effectively converting widespread willingness into documented commitment, which necessitates a clear strategic shift toward institutional facilitation to motivate the willing majority. To realize this strategic shift, we recommend: (a) deploying mobile and workplace registration units with digital reminders, (b) shifting resources from broad awareness to process facilitation and trust-building initiatives, and (c) monitoring conversion metrics and adapting outreach by gender and education level.

Limitations

This study provides valuable insights, but our findings must be interpreted in context. The cross-sectional data were used to establish correlations rather than causality; therefore, contemporary replication is warranted. Our sample was geographically diverse, but disproportionately represented by participants from two regions (over 75%), limiting broader regional insights. The web-based convenience sample also skewed toward higher education levels, potentially overestimating awareness and favorable attitudes compared with the general population. Utilizing multi-channel recruitment strategies and adopting validated study instruments are both necessary to achieve broader representation and establish reliability metrics. To overcome measurement constraints, validating self-reported registration and incorporating qualitative insights could further strengthen our findings, and provide a deeper understanding of the emotional and cultural factors that influence organ donation.