Development and validation of a questionnaire on knowledge, attitudes, and intent toward organ donation among undergraduate medical students in Punjab, Pakistan: a cross-sectional study

End-stage organ failure remains a leading cause of morbidity and mortality worldwide. Organ transplantation is the most effective treatment for irreversible organ dysfunction; however, donation rates remain critically low in many low- and middle-income countries, including Pakistan. Understanding knowledge, attitudes, and intent toward organ donation among future healthcare providers is essential for designing effective educational interventions. Cultural, religious, and societal factors strongly influence organ donation behavior in Pakistan, yet no validated, context-specific instrument exists to systematically assess these determinants among medical students. To develop and psychometrically validate a questionnaire assessing knowledge, attitudes, and intent toward organ donation among undergraduate medical students in Pakistan using exploratory and confirmatory factor analysis. A multicenter cross-sectional study was conducted among undergraduate medical students from five medical universities in Punjab, Pakistan. A questionnaire was developed through literature review, expert panel evaluation, and cognitive testing, followed by psychometric validation. Exploratory factor analysis (EFA) was performed to identify the underlying factor structure, and confirmatory factor analysis (CFA) was used to assess model fit. Internal consistency was evaluated using Cronbach’s alpha. Receiver operating characteristic (ROC) curve analysis was conducted to determine an optimal cut-off score for predicting willingness to donate organs. A total of 425 students participated. Exploratory factor analysis identified a six-factor structure: (1) Eligible donor and needed recipient, (2) Benefits of organ donation, (3) Scientific and religious knowledge about organ donation, (4) Fears about organ donation, (5) Barriers to organ donation registration, and (6) Organ donation mindset in Pakistan. Confirmatory factor analysis demonstrated acceptable model fit (CFI = 0.94, TLI = 0.91, RMSEA = 0.059). The overall questionnaire showed acceptable internal consistency (Cronbach’s alpha = 0.61), with subscale values ranging from 0.621 to 0.837. ROC analysis yielded an area under the curve of 0.716, with an optimal cut-off score of ≥36, demonstrating moderate accuracy in predicting willingness to donate organs. This study developed and validated a culturally sensitive, six-factor questionnaire to assess Pakistani undergraduate medical students’ knowledge, attitudes, and willingness regarding organ donation. The tool demonstrated good reliability and acceptable model fit, supporting its utility in capturing key sociocultural influences on donation perceptions. While findings suggest roles for religion, trust in healthcare, and procedural barriers, the study’s primary aim was tool validation, and these trends require further investigation. The validated instrument offers a valuable resource for future research and targeted educational interventions, though its generalizability is limited to similar populations and does not encompass all psychosocial determinants.