Attitude and personal characteristics as predictors for registration to organ donation in Saudi Arabia: A binary logistic regression model

Abstract

Introduction:

The registration of future organ donors offers hope to thousands of individuals and supports the mission of the Saudi Center for Organ Transplantation (SCOT). Despite the availability of the Tawakkalna app (a national digital platform designed to simplify donor registration), actual donation rates in Saudi Arabia remain low. Understanding the personal and attitudinal factors that influence registration is crucial to bridging the gap between willingness and behavior.

Purposes:

This study aims to investigate the relationship between attitudes toward organ donation and seven personal characteristics that influence registration behaviors for posthumous organ donation (age, gender, marital status, education, employment, smoking status, and comorbid conditions) using the Tawakkalna app in the Western region of Saudi Arabia.

Methods:

A quantitative approach with a cross-sectional design was employed to achieve the study’s objectives. A total of 1,482 respondents participated in an online survey conducted through convenience sampling. A logistic regression model through SPSS version 25 was employed to compare factors associated with registration behaviors for posthumous organ donation.

Results:

The study found that the registration rate for posthumous organ donation was 26%, Individuals with higher attitude scores were significantly more likely to register as organ donors (p < 0.001, OR = 2.760, 95% CI: 2.262–3.368). Younger participants, non-smokers, and those without comorbid conditions also showed higher odds of registration (all p < 0.05). In contrast, factors such as gender, education level, marital status, and employment status did not show a significant relationship.

Discussion and Conclusion:

Findings highlight that positive attitudes, younger age, and better health status are key determinants of organ donation registration through digital platforms. The results underscore that technological accessibility alone does not guarantee engagement; behavioral and health-related factors remain critical. Posthumous organ donation is a controversial topic within the Muslim context. The findings could be valuable for policymakers striving to increase organ donation registration rates and can help address gaps in the current literature on this subject. These insights can inform targeted awareness campaigns, culturally aligned behavioral interventions, and digital health policies aimed at enhancing donor registration rates and closing the attitude–behavior gap in Saudi Arabia.

Plain language summary

Determinants of Organ Donation Registration via Digital Platform in Saudi Arabia

A single deceased organ can significantly impact the lives of many organ recipients, either by saving their lives or improving their quality of life. Achieving a high rate of registration ultimately contributes to overall community health. However, the actual rate of deceased organ donation in Saudi Arabia remains relatively low. This study aims to compare attitudes toward organ donation and personal characteristics with registration to the posthumous organ donation Tawakkalna app in the Western region of Saudi Arabia. This study found that the registration rate for organ donation in the study sample (n = 1,482) was 26%. The model clearly indicates that a positive attitude toward organ donation is significantly associated with the likelihood of registering as an organ donor (p < 0.001, OR = 2.760, 95% CI: 2.262–3.368). The results from the Wald test indicated that age over 18 years, comorbid conditions, and smoking status were all significantly associated with registration behaviors for organ donation (p < 0.05). On the other hand, level of education, marital status, and working status failed to reject the null hypothesis, and mean not significantly associated with registration behaviors of organ donation. Hence, understanding the factors influencing the registration rates can aid in policymaking, direct policy investments, and identify specific groups that require further policies and interventions. Designing an ethical opt-out policy for deceased organ donation, which is approved by religious authorities, is likely to enhance donation opportunities among the elderly population. In addition, it is crucial to engage younger individuals, particularly university students, by incorporating awareness programs into relevant courses, as they represent a vital source for future donations.

Introduction

Organ donation remains a vital and life-saving medical practice, in which viable organs or tissues are transplanted from a donor to a recipient to restore or significantly enhance the quality of life. Donors can be either living or deceased; however, the demand for organ donations has dramatically increased compared to the number of people who are willing to register for posthumous organ donation. ¹ Organ donation issue is still an international concern considering religious, ethical, and legal acceptance and applications that vary between countries. International data shows that 39.8% of adults in the United States and 44% in the Netherlands are registered as organ donors.^2,3 This is contrary to Islamic countries and Middle Eastern nations, which have a lower percentage of registration for organ donation. ⁴ – ⁷ These differences have been attributed not only to cultural and religious interpretations but also to systemic and behavioral factors affecting donor registration.

The registration mechanism plays a significant role in this regard; the methods for registering deceased donors differ across countries. For instance, in North America and many European countries, registration for deceased organ donation can often be done through a driver’s license or ID card. ² However, the organ donation culture is advanced compared to the Middle East and Gulf countries. In contrast, Saudi Arabia has adopted a centralized digital system through the Tawakkalna national mobile Application to streamline and legalize the registration of deceased organ donors. Due to impotent of organ donation in the modern health care system, several countries have established their own center to control and regulate organ donation. For example, the Saudi Center for Organ Transplantation (SCOT) is the national authority overseeing donation and transplantation policies in Saudi Arabia. SCOT has introduced various incentives to promote organ donation, including honorary awards and healthcare privileges. ⁸ Deceased donor transplants programs were launched in 1985 by SCOT, ⁹ and provide several initiatives and regulations to encourage this kind of donation. Despite these efforts, the registration rate for posthumous donation remains disproportionately low in Saudi Arabia and other Gulf countries,^10,11 compared to the growing public awareness and generally positive attitudes toward donation.^1,2,12

As per SCOT statistics, there have been approximately 393 organ transplantations from deceased donors and 1,706 from living donors, indicating a significant gap between intention and actual registration behavior. ⁹ These figures reflect a broader disconnect that persists even as public awareness and positive attitudes toward donation are reportedly increasing.^1,4,12 International comparisons highlight this discrepancy. According to the International Registry in Organ Donation and Transplantation (IRODaT), the deceased donor rate in Saudi Arabia is 3.33 per million population (pmp). This rate is slightly higher than in some other Middle Eastern countries, such as 2.5 pmp in Qatar and 2.88 pmp in Lebanon, but lower than in Bahrain of 4 pmp, and dramatically less in the United Arab Emirates, which had a rate 28.95 transplants pmp in 2023. ¹³ The deceased donor rates in Saudi Arabia are comparable to those in several Asian countries: China (4.43 pmp), Thailand (3.66 pmp), Japan (0.75 pmp), and India (0.65 pmp). However, western countries exhibit much higher deceased donor rates compared to Saudi Arabia, with Spain at 48.9 pmp, the United States at 36.88 pmp, the United Kingdom at 24.88 pmp, and Australia at 22.17 pmp.^14,15 This indicates a significant discrepancy between Western and Eastern countries in this context. A few descriptive studies focusing on deceased organ donation are available. While regional studies suggest variable yet consistently low registration rates—from 5.1% to 30%—they all point to the same conclusion: there is a substantial gap between willingness to donate and actual registration.^4,6,7,12 This persistent gap raises critical questions about the factors influencing the decision to register, even when accessibility barriers have been largely removed through digital systems.

Previous studies in Saudi Arabia and the broader Gulf region have explored willingness, knowledge, and attitudes toward organ donation,^4,7,16 but few have examined the determinants of actual registration behavior, particularly in the context of digital registration platforms. Several factors associated with organ donation, including attitudes, intentions, willingness, awareness, knowledge, and religious beliefs, and most notably, individual attitudes.^12,16– ¹⁹ Within the framework of the Theory of Planned Behavior, attitude has consistently emerged as a strong predictor of intention and willingness to register. ¹⁵ Attitude plays a crucial role in understanding registration behavior. In this context, attitude is defined as a person’s way of thinking toward something, which ultimately influences their behavior. However, intention alone is insufficient to close the donor gap. Translating positive attitudes into concrete behaviors—such as registration—is crucial for improving donation outcomes.

Despite the introduction of the Tawakkalna mobile application as a national digital platform for registering organ donation consent in Saudi Arabia, the uptake of this service remains disproportionately low. While the app provides a legally recognized and easily accessible means for adults to register as deceased organ donors, current statistics reveal that actual registration rates lag far behind public expressions of willingness and positive attitudes toward organ donation. This persistent gap between intention and behavior suggests that structural convenience alone is insufficient to drive donor registration. Therefore, a critical need exists to identify and understand the individual-level factors that may hinder or facilitate registration despite the availability of a digital opt-in system. To address this gap, the present study examines the relationship between attitudes toward organ donation and a range of personal characteristics—including age, gender, marital status, education level, employment status, smoking behavior, and presence of comorbid conditions—that may influence registration behavior through Tawakkalna in the Western region of Saudi Arabia. By clarifying the determinants of registration within a context of digital accessibility, this research aims to inform targeted interventions and policy strategies to enhance donor enrollment and ultimately increase organ availability for transplantation.

Methods

Study design, setting, and population

This study employed a quantitative, descriptive cross-sectional design by using a self-reported survey to examine the relationship between attitudes and personal characteristics associated with registration for posthumous organ donation through the Tawakkalna digital platform in the Western region of Saudi Arabia. The target population of this study comprises Western region inhibitors in Saudi Arabia, a highly populated and diverse area that includes major urban centers such as Jeddah, Mecca, and Medina. According to the population Statistics, the total population in the western region is around 10,150,000. ²⁰ The study was conducted between March 1 and May 30, 2025, allowing for comprehensive public access to both male and female participants in culturally appropriate venues.

Study sampling and sample size

A non-probability sampling, specifically convenience sampling was used to recruit the study participants due to the absence of a national registry of potential participants and logistical considerations associated with public data collection. This approach enabled rapid recruitment from diverse demographic backgrounds while ensuring inclusivity across genders and age groups. However, it is acknowledged that convenience sampling may introduce selection bias and limit the generalizability of the findings. To mitigate this limitation, efforts were made to maximize demographic diversity by distributing the survey across multiple venues and platforms. Moreover, convenience sampling was ethically and practically appropriate, as participation was entirely voluntary and anonymous, and recruitment in public settings minimized coercion or institutional bias.

The sample size was calculated by using the Krejcie and Morgan formula to compute the sample size based on the National Education Association (NEA). ²¹ Based on Krejcie and Morgan’s table for determining sample size, for a given population of 10,150,000, the sample size of 384 would be needed to represent the study population. However, to enhance statistical power and reliability, a total of 5000 surveys were distributed and 1,482 complete responses were ultimately included in the analysis.

Data collection approach

Data were collected via a self-administered online questionnaire distributed using QR codes placed in public venues such as shopping malls, parks, and streets. A trained distribution team of three trained investigators from both genders (two female and one male, to ensure gender inclusivity) was recruited to complete the data collection process. They had distributed study survey as a QR code to the public in various locations. The QR code was also being shared through social media platforms (Twitter, Instagram, and WhatsApp) to reach a wider audience as well. A distribution team helped elderly and illiterate people to answer the study survey.

Inclusion criteria

The inclusion criteria for this study were (1) Inhibitors currently residing in the Western Region of Saudi Arabia, (2) Adults aged 18 years and older, (3) The participation was entirely voluntary and anonymous, respondent must be able to provide consent for participation.

Measures

The survey instrument was available in both Arabic and English. The questionnaire was translated into Arabic using back-to-back translation techniques by three bilingual healthcare scholars to ensure cultural and linguistic validity. The online questionnaire, created through a Google Form, included one binary item to measure the dependent variable: 1 for “I have registered as a deceased organ donor in the Tawakkalna app” and 0 for “I have not registered as a deceased organ donor in the Tawakkalna app.” This measure was adapted from Reubsaet et al.’s study. ²²

Attitudes toward organ as donation, the independent variable in this study was assessed using five items rated on a five-point scale, where 5 represents "strongly agree" and 1 represents "strongly disagree," to assess attitudes toward organ donation. An example of an item is: “I am willing to donate my organs after death.” The items measuring attitudes toward organ donation were adapted from validated scales.^23,24 The attitude score was treated as a continuous variable, with higher scores indicating more favorable attitudes toward organ donation. Other independent variables included seven personal characteristics: age, gender, marital status, education level, employment status, smoking status, and presence of comorbid conditions. These were self-reported and categorized accordingly for analysis.

Prior to full deployment, a pilot test was conducted with a sample of 75 adults from the same population to assess the clarity and reliability of the survey instrument, yielding a Cronbach’s alpha of 0.91, indicating excellent internal consistency. Minor linguistic adjustments were made based on participant feedback. The final reliability and validity of the study instrument were approved as part of a larger project by Batterjee Medical College, titled “The Impact of Extraversion Personality and Knowledge of Organ Donation on Intention and Behaviors of Organ Donation.”

Ethical considerations

Ethical approval was obtained from the Research Ethics Committee of Batterjee Medical College, with reference number RES-2025-0051. The study adhered to the principles outlined in the Declaration of Helsinki and ensured anonymity, privacy, and the right to withdraw at any point. The study complied with the Saudi Ministry of Health research regulations regarding national data privacy. Surveys were conducted in public spaces (malls, parks, streets) where both men and women were accessible. QR codes allowed voluntary and anonymous participation without direct interviewer interaction, ensuring cultural appropriateness. Informed consent was obtained digitally, and no personal identifiers were collected (e.g., name, email, or IP address), ensuring complete anonymity. At the beginning of the online data collection, participants were presented with a clear informed consent statement outlining the study’s purpose, voluntary nature, confidentiality safeguards, and contact information of the principal investigator, and they were informed that they could withdraw at any time by closing the survey without consequence.

Statistical analysis approach

Data were screened for completeness prior to analysis. Then, data analysis was performed using version 25 of SPSS. Descriptive statistics (frequencies, percentages, means, and standard deviations) were calculated to summarize participant characteristics and responses. Bivariate associations between categorical independent variables and registration behavior were examined using the Chi-square test.

The logistic regression analysis was followed Harris to identify factors independently associated with the likelihood of being registered as a deceased organ donor. ²⁵ The dependent variable was binary (registered vs not registered), and the independent variables included both categorical (e.g., gender, smoking status) and continuous (attitude score) variables. The internal consistency of the five items measuring attitudes toward organ donation was assessed using Cronbach’s alpha, which yielded a value of 0.91. The mean score (± SD) for attitudes toward organ donation was 3.17 ± 0.92. Other categorical explanatory variables were analyzed using frequency, percentage, and chi-square methods in this study (see Tables 1 and 2).

Table 1.

Categorical explanatory variables frequency, percentage, and chi-square.

Variables	Category	Number and Frequency (N = 1482)	Registered (N = 386) (26.0%)	Not registered (N = 1096) (74.0%)	df	Chi-square (p-value)
Age	18–30 years	382 (25.7%)	125 (32.4%)	257 (23.4%)	4	18.05 (0.001)
	31–40 years	396 (26.7%)	100 (25.9%)	296 (27.0%)
	41–50 years	326 (21.9%)	84 (21.8%)	242 (22.1%)
	51–60 years	201 (13.5%)	48 (12.4%)	153 (14.0%)
	>60 years	177 (11.9%)	29 (7.5%)	148 (13.5%)
Gender	Male	703 (47.4%)	201 (28.5%)	502 (71.5%)	1	4.50 (0.034)
	Female	779 (52.6%)	185 (23.7%)	594 (76.3%)
Education	Illiteracy	58 (3.9%)	15(3.9%)	43(3.9%)	4	1.219 (0.875)
	Secondary school	371 (25.0%)	94(24.4%)	277 (25.3%)
	Bachelor degree	808 (54.5%)	211 (54.7%)	597 (54.5%)
	Master degree	182 (9.8%)	46 (11.9%)	136 (12.4%)
	PhD	63 (4.2%)	20 (5.2%)	43 (3.9%)
Marital status	Single	380 (25.6%)	110 (28.5%)	270 (24.6%)	2	2.47 (0.291)
	Married	969 (65.3%)	245 (63.5%)	724 (66.1%)
	Divorced or widowed	133 (8.9%)	31 (8.0%)	102 (9.3%)
Working status	Yes	834 (56.2%)	221 (57.3%)	613 (55.9%)	1	0.20 (0.652)
	No	648 (43.7%)	165 (42.7%)	483 (44.1%)
Smoking status	Yes	456 (30.7%)	158 (34.6%)	298 (65.4%)	1	25.31 (0.000)
	No	1026 (69.2%)	228 (22.2%)	798 (77.8%)
Comorbidity disease	Yes	199 (13.4%)	82 (21.2%)	117 (10.7%)	1	27.43 (0.000)
	No	1283 (86.6%)	304 (78.8%)	979 (89.3%)

Note. p < 0.05.

Table 2.

Significant results of logistic regression on organ donation registration behaviors.

Variables	B	S.E.	Wald	df	Sig.	Odds Ratio	95% CI for Odds Ratio
							Lower	Upper
Age (years) (vs age 18–30 years)			26.609	4	.000
31–40 years	−.443	.174	6.482	1	.011	.642	.457	.903
41–50 years	−.581	.184	9.932	1	.002	.559	.390	.803
51–60 years	−.560	.219	6.528	1	.011	.571	.372	.878
>60 years	−1.220	.250	23.775	1	.000	.295	.181	.482
Comorbidity Disease (vs No Comorbidity Disease)	−1.123	.179	39.223	1	.000	.325	.229	.462
Smoking Status (vs Not Smoking)	−.646	.137	22.278	1	.000	.524	.401	.686
Attitude toward Organ Donation	1.015	.102	99.897	1	.000	2.760	2.262	3.368

Results

Response rate and personal characteristics

In a targeted population study, 5,000 online surveys were distributed to the general public in various public locations, including malls, streets, and gardens, as well as through social media, between March and May 2025. Respondents were not required to provide their names or any unrelated information regarding the study’s objectives. They were informed about the purpose and benefits of the study. A total of 1,482 respondents successfully completed the survey, resulting in a response rate of 30%, which is generally considered acceptable for this type of study. The personal characteristics analyzed in this study revealed that a majority of respondents (n = 1,096, 74%) were not registered as organ donors, while the percentage of registered donors was 26%. Among the total participants (n = 1,482), most identified as married (n = 969, 65.3%), held a bachelor’s degree (n = 808, 54.5%), were employed (n = 834, 56.2%), were non-smokers (n = 1,026, 69.2%), and had no comorbidities (n = 1,283, 86.6%). Table 1 provides additional details regarding the socio-demographic characteristics of respondents who are registered and those who are not registered for organ donation through the Tawakkalna app.

Bivariate analysis

Chi-square (χ2) is a non-parametric statistic and can examine the link between dependent and independent variables. ²⁶ Accordingly, age, gender, smoking status, and the existence of comorbid disease rejected the null hypothesis (p < 0.05), thus, significantly associated with registration behaviors of organ donation. Contrary to expectations, level of education, marital status, and working status failed to reject the null hypothesis, and mean not significantly associated with registration behaviors of organ donation. (See Table 1)

In addition to the Chi-square (χ²) test, calculating the Odds Ratio is essential for interpreting both the strength and direction of the association. A logistic regression was conducted using the Wald test, which is commonly employed in studies with binary dependent variables.^1,15 The Wald test was utilized to test the hypotheses concerning the regression slope coefficient, where the null hypothesis (H₀) is that βᵣ = 0 and the alternative hypothesis (H₁) is that βᵣ ≠ 0. ²⁷ The results from the Wald test as shown in Figure 1 indicated that age over 18 years, comorbid conditions, smoking status, and attitudes toward organ donation were significantly associated with registration behaviors for organ donation (p < 0.05).

Figure 1.

Wald test results of the study conceptual framework.

p < 0.05.

In more detail, Table 2 indicates that respondents aged 31–40 years exhibited the highest contribution to registration behaviors (p = 0.011, OR = 0.642, 95% CI: 0.457–0.903), followed by those aged 41–50 years (p = 0.002, OR = 0.559, 95% CI: 0.390–0.803), 51–60 years (p = 0.011, OR = 0.571, 95% CI: 0.372–0.878), and those over 60 years (p < 0.001, OR = 0.295, 95% CI: 0.181–0.482). This indicates that the likelihood of engaging in registration behaviors for organ donation decreases significantly with increasing age. In addition, respondents without comorbid conditions were significantly more likely to register for organ donation compared to those with comorbidities (p < 0.001, OR = 0.325, 95% CI: 0.229–0.462). Nonsmokers also showed a higher likelihood of registering to donate than smokers (p < 0.001, OR = 0.524, 95% CI: 0.401–0.686). Finally, respondents who held a positive attitude toward organ donation were more likely to register through the Tawakkalna App compared to those with a negative attitude (p < 0.001, OR = 2.760, 95% CI: 2.262–3.368).

The Hosmer-Lemeshow test was used to evaluate the goodness of fit for the logistic regression models employed in the study. The resulting value of 0.083 is greater than 0.05, indicating that the model fits the data reasonably well. ²⁸ In addition, Fisher’s linear discriminant analysis was conducted to assess the classification accuracy of the study model, achieving an acceptable accuracy level of 96.4%. ²⁹

Discussion

The registration of future organ donors provides hope to thousands of individuals and allows organizations like the SCOT to carry out their vital mission. However, this effort faces several challenges in Saudi Arabia.^4,7 This study examined how attitudes and personal characteristics influence registration for organ donation through the Tawakkalna digital platform in Saudi Arabia. The findings reveal that positive attitudes toward organ donation, younger age, non-smoking status, and the absence of comorbid conditions were significant predictors of registration behavior.

Organ donation registration

According to the current study findings, approximately one-quarter of study respondents were registered as deceased organ donors through the Tawakkalna app. Thus, a possible justification of this finding is related to the sample that was drawn from the Western Region, an area with strong public health promotion activities. Moreover, the Tawakkalna app’s integration with daily digital services may have increased registration visibility. Finally, self-reporting may have inflated actual rates. Hence, we also emphasize that these findings should be interpreted cautiously and may not represent all Islamic or Gulf countries. However, this aligns with another study indicating that 21% of the general population in Saudi Arabia (n = 2,329) are recognized as potential deceased organ donors, ⁴ and 30% were registered for organ donation among 3,111 surveyed persons, ⁷ while 19.6% said they would register if asked to donate. ¹ In contrast, a study by Alghalyinis et al. found that the registration rate of deceased donors in the Saudi capital was only 9.5% among 645 respondents in 2023. ¹² In addition, Al Salem’s study reported that just 5.1% of 1,022 respondents were registered with SCOT. ⁷ Saudi results for the registration rate of organ donation are consistent to other Gulf countries. ¹⁰ In comparison, international data shows that as of 2010, 39.8% of adults in the United States aged 18 and older were designated organ donors, ³ and 44% of the adult population in the Netherlands is registered as organ donors. ² These findings highlight the disparities in deceased donor registration rates and confirm the existing gap in organ donation intentions and behaviors.

Attitude toward organ donation

The results of this study highlight the factors that influence organ donation registration behaviors. The model clearly indicates that a positive attitude toward organ donation is significantly associated with the likelihood of registering as an organ donor. This finding provides consistent results with the Theory of Planned Behavior (TPB). The TPB posits that behavioral intentions are shaped by attitudes, subjective norms, and perceived behavioral control. ³⁰ Despite few studies have examined the connection between attitudes and registration behaviors through digital platforms on a national scale. ¹² However, previous research has consistently shown that attitude is closely related to the willingness and intention to register for organ donation.^3,15,31,32 This reflects an attitude–behavior gap, where favorable attitudes do not consistently translate into actual behavior. As shown in other domains of health behavior, such as chronic disease self-management, attitudes alone are insufficient without mechanisms that empower individuals to act on their intentions. For instance, Jarrar et al. demonstrated that shared decision-making and self-management behaviors significantly improved health outcomes among patients with type 2 diabetes, underscoring the importance of active behavioral engagement in achieving desired outcomes. ³³ In the Saudi context, this gap may stem from perceived social sensitivities surrounding death, limited awareness of the Tawakkalna registration function, or doubts about the religious permissibility of donation despite official endorsements by Islamic authorities. ¹⁰

Donor registration depends not only on attitude but also on trust in digital systems and perceived data security. ¹⁵ Thus, even when individuals hold favorable views of organ donation, uncertainty about how digital consent is recorded or used may deter them from finalizing registration. Accordingly, we can conclude that promoting a positive attitude toward deceased organ donation among the general population is essential for increasing the availability of organs for patients in need of transplantation.

Personal characteristics and organ donation

In regard to personal characteristics, the study found a significant association between age and behaviors related to organ donation registration. Younger and middle-aged adults (18–30 and 31–40 years) show a greater likelihood of organ donation registration compared to other age groups. Age was identified as a likely factor influencing these behaviors, which is consistent with Irving et al.’s study. ³⁴ Conversely, older individuals, particularly those over 60, showed lower registration rates, aligning with findings from a previous study. ⁴ It’s important to note that most brain death cases occur among the elderly, and many of these individuals are not registered as donors, ² further supporting the observation that registration behaviors tend to decrease with age. These younger and middle-aged adults demonstrated higher involvement in organ donation registration, consistent with previous studies,^11,12,18,35 and corroborated by international literature, ³¹ where younger individuals demonstrate higher engagement in digital platforms and social responsibility campaigns. Younger adults may also be more familiar with the Tawakkalna app and other e-government services, which facilitate registration. In contrast, older adults (who may be less digitally literate or hold more conservative religious interpretations) appear less likely to register. Culturally sensitive educational interventions, such as family-centered discussions or mosque-based awareness sessions, may therefore enhance registration among older populations.

The decision to register for organ donation was associated with gender. In this study, however, there was no significant difference in registration behavior between men and women, which aligns with a previous study conducted in the central region of Saudi Arabia. ¹² Conversely, another study in Saudi Arabia found that females are more likely to self-register for organ donation than males. ⁴ In addition, an international review by Wakefield et al. indicated that four studies reported men being less willing to donate than women. ³¹ This discrepancy may be explained by the higher tendency for empathy, emotional sensitivity, and emotional recognition typically found among women.^36,37

Previous literature did not examine the relationships between comorbid diseases, marital status, smoking status, and employment status with registration behavior. This study contributes to the existing body of research by demonstrating that the presence of comorbid diseases is significantly associated with registration behaviors. Respondents with comorbid diseases tend to pay less attention to organ donation compared to those without such conditions. Evidence suggests that comorbidities serve as a barrier to registering as a donor, ⁴ while a willingness to donate could potentially lead to registration, not all willing donors choose to register as deceased donors. Some studies have indicated that individuals with comorbid conditions demonstrate less willingness to donate organs after death. ³⁵

In addition, smoking status was significantly associated with registration behaviors; respondents who smoked were less likely to register as organ donors compared to non-smokers. This may be linked to the physical and psychological health perceptions of non-smokers, who might believe their organs are healthier and more beneficial for recipients than those of smokers. Moreover, some smokers worry that transplantation policies and guidelines may restrict their ability to donate, leading them to prefer non-smokers’ organs. ³⁸ Smokers and individuals with chronic illnesses may perceive their organs as “less suitable” for transplantation or feel morally or medically disqualified from donation.

The relationships between education, marital status, and employment status and registration behaviors were not significant. However, a previous study indicated that unemployed individuals and those with lower levels of education are less likely to donate compared to employed individuals and those with higher education, ³⁵ In contrast to our finding of no significant association between respondent qualifications or education levels and registration behaviors, Alhasan et al. discovered that individuals with bachelor’s degrees were more likely to decide to register for organ donation compared to those with other education levels. ⁴ In addition, Alghalyini et al. found that respondents who had completed high school were more likely to register than those who did not finish high school. ¹² Our study findings reinforce the notion that psychological and informational factors, rather than structural ones, primarily drive registration behavior in the Saudi context.

Study implications and recommendations

Given the significance of donor registration behavior in increasing deceased organ donations and enhancing overall population health—particularly for patients with organ failure—this study investigates the registration habits for deceased donor registration among the general population in the western region of Saudi Arabia. Understanding the factors influencing the registration rates can aid in policymaking, direct policy investments, and identify specific groups that require further policies and interventions. Designing an ethical opt-out policy for deceased organ donation, which is approved by religious authorities, is likely to enhance donation opportunities among the elderly population. In addition, it is crucial to engage younger individuals, particularly university students, by incorporating awareness programs into relevant courses, as they represent a vital source for future donations. Reaching target age groups through public campaigns utilizing television, radio, and social media is a viable approach. ³⁹ Furthermore, it is recommended to establish a specialized psychological support team to foster positive attitudes toward donor registration, assisting health policymakers in this effort.

Strengths, limitations, and future studies

Despite the several noteworthy contributions of this study, such as investigating personal characteristics for the first time and involving a substantial number of respondents in a new context. However, some limitations must be acknowledged, Such as the selected Western Region in Saudi Arabia may not represent other Gulf or Arab states due to cultural and demographic differences. In addition, the potential for social desirability bias due to the reliance on self-reported registration via the Tawakkalna app, not physical donor cards. The use of convenience sampling may limit the generalizability of the findings to the entire Kingdom of Saudi Arabia and other Gulf countries. Furthermore, the cross-sectional design of the study means that causal relationships cannot be established. Future research should focus on the mechanisms that influence registration behavior related to decreased organ donation. It is also essential to employ probability sampling methods to mitigate any potential biases. Finally, studies that establish a framework for an opt-out policy for deceased organ donation should be prioritized by policymakers.

Conclusion

One deceased organ can significantly impact the lives of multiple organ recipients, either by saving their lives or improving their quality of life. This study underscores that while digital systems like Tawakkalna facilitate the logistics of organ donation registration, behavioral and perceptual factors remain decisive. Reaching high percentage of registration ultimately contributes to overall community health. However, the actual rate of deceased organ donation in Saudi Arabia remains relatively low. This study found that the registration rate for decreased organ donation as 26%. Using a logistic regression model, the study concluded that a positive attitude toward donation, age, smoking status, and the presence of comorbid conditions were significantly associated with individuals’ registration behaviors regarding organ donation. In contrast, factors such as gender, education level, marital status, and employment status did not reach a significant level. Therefore, the findings of this study could be valuable for policymakers aiming to increase donation rates. Addressing psychological barriers, enhancing digital trust, and integrating behavioral insights into national e-health strategies may ultimately improve donor registration rates and strengthen the culture of organ donation in Saudi Arabia.