Application of Automated External Defibrillators Among the Public: A Cross-Sectional Study of Knowledge, Attitude, Practice, and Barriers of Use in Saudi Arabia

Introduction

Out-of-hospital cardiac arrest (OHCA) is a crucial health problem associated with the high incidence and mortality of cardiovascular disease.^1,2 The prehospital management of such cases is ineffective as it is usually applied late, although scientific evidence shows that early basic cardiopulmonary resuscitation (CPR) performed by bystanders can enhance the patient survival rate up to four times.^3–5 Meanwhile, the early basic life support (BLS) procedure is vital to improving the prognosis of OHCA, including immediate defibrillation, if available, as it forms part of the third link in the patient sequence of survival.^6–8

Initial defibrillation and public access to automated external defibrillators (AEDs) have been shown to increase survival rates by two-thirds.^9–11 When carried out in the first 3–5 minutes after the collapse, survival rates of up to 50–70% have been reported, provided that the previous steps (ie, recognition of cardiac arrest [CA], activation of the emergency system, and start of CPR have been correctly executed.^12–14 Incidentally, for every minute in which defibrillation is postponed, survival decreases by 7–10%.^2,15 Currently, there are many centers that train for BLS and heart savor courses all over the country. AEDs also available for public use in airports, the two holy mosques and in all mass gatherings events.

The present study aimed to evaluate the use of AEDs by the public and assess their knowledge, attitude (willingness to use AED), practice (KAP), and barriers of use during OHCA cases. Ultimately, we aimed to develop recommendations for future generations and to provide instructions in using the device to save as many lives as possible.

Methods

Study Design, Setting and Population

A cross-sectional study using a web-based survey was conducted among adults aged >18 years, currently living in Saudi Arabia. We prepared a structured questionnaire comprising 21 multiple-choice questions. The first part of the questionnaire included demographic data of the participants. The second part (questions 8 to 21) tests the knowledge of AED used and inquire about the reasons for not using the AED. It was tested in a pilot study with 20 participants and reviewed by five experienced emergency physicians. The survey was posted on March 1, 2022, and closed on March 30, 2022. The sample size was calculated using a margin of error of 2.5%, confidence interval (CI) of 95%, 50% response distribution, and six million individuals from www.Rasoft.com, resulting in an approximate population of 385 target participants. The online survey was conveniently distributed to 700 participants in Riyadh through social media channels. Data were collected using an anonymous electronic structured questionnaire. The questionnaire was designed to collect KAP information concerning use of AED devices during emergency situations as well as the participants’ demographics, including age, sex, nationality, occupation, and level of education.

Statistical Analysis

Descriptive statistics, such as the mean and standard deviation (SD), were computed for quantitative variables, and frequencies and percentages were calculated for categorical variables. Differences in means were evaluated using the t-test. The differences in KAP scores with respect to individual covariates were evaluated using the Mann–Whitney U and Kruskal–Wallis tests. Binary logistic regression was used to compute odds ratios with 95% confidence intervals (CIs) and to assess the presence and degree of association between the dependent and independent variables. Variables with a p-value <0.05 in the bi-variable analysis were used for multivariate analysis. Spearman correlation was used to assess the association between knowledge and attitude. All tests were two-sided, and statistical significance was set at a p-value < 0.05. All statistical analyses were performed using SPSS software (SPSS Inc., Chicago, IL, USA).

Results

A total of 406 individuals with a median age of 32.64 years responded in the online survey. The average age of participants who received and did not receive BLS/CPR training was 33.88±10.97 and 31.13±10.97, respectively. Overall, 244 (60.10%) were males and 162 (39.90%) were females (Table 1). Among male and female respondents, 139 (62%) and 84 (37.7%) had CPR/BLS training, respectively.

Table 1 Participants’ Sociodemographic Details

Moreover, 296 (72.90%) were Saudi nationals and 110 (27.10%) were of a foreign nationality. A total of 165 (55.74%) Saudi nationals and 58 (52.72%) foreign nationals were trained for CPR/BLS.

Our study included 117 students, 146 employees, 81 health workers, and 62 non-workers. Fifty-three students (45.2%) and 72 (49.3%) employees had training on CPR/BLS while only three health workers (3.7%) were not trained for CPR/BLS. Among non-workers, 42 (67.7%) were not trained and 20 (32.2%) were trained for CPR/BLS.

Additionally, Table 1 shows the educational attainment of the respondents, of whom, 10 (2.5%) had an elementary level education, 98 (24.1%) had a secondary level education, 231 (56.9%) had university-level qualifications, and 67 (16.5%) had higher education. Among the participants who received training on CPR, 3 (1.3%), 39 (17.5%), 137 (61.4%), and 44 (19.7) had elementary, secondary, university, and higher levels of education, respectively.

Among the respondents untrained on CPR/BLS, 7 (3.8%) had elementary education, 59 (32.2%) had secondary level, 94 (51.4%) had university level, and 23 (12.6%) had higher education. The relationship between CPR attitude and knowledge.

Table 2 shows the top concerns among respondents with training on CPR/BLS prior to using AEDs. These include (1) accidentally hurting the victim (n = 32, 14.3%); (2) duty as a bystander is just to call the ambulance and wait for help to arrive (n = 27, 12.1%); (3) never taught what to do (n = 41, 18.4%); (4) do not want to be scolded if I do the wrong thing (n = 7, 3.1%); and (5) never witnessed such a situation (n = 115, 51.6%).

Table 2 Barriers of AED Use Among Respondents

Meanwhile, respondents who were not trained on CPR/BLS expressed the following as their reasons for not using AEDs: (1) accidentally hurting the victim (n = 39, 21.3%); (2) duty as a bystander is just to call the ambulance and wait for help to arrive (n = 42, 23%); (3) never taught what to do (n = 73, 39.9%); (4) do not want to be scolded if I do the wrong thing (n = 13, 7.1%); and (5) never witnessed such a situation (n = 103, 56.3%).

Table 3 shows the factors influencing the respondents’ knowledge and attitude on AED use. As the respondent’s age increases, with OR 1.00 (0.97–1.03), knowledge and attitude toward AED utilization both increase by 0.3% (Table 2). Male respondents had a 17% lower knowledge and attitude of AED use (with OR 0.82 [0.46–1.48]) as compared to females. Compared to foreign nationals, Saudi nationals had decreased knowledge and attitudes toward AED utilization by 70.7%. Being a student, employee, or non-worker reduced the odds of knowledge and attitude toward AED utilization by 90.1%, 88.9%, and 87.6%, respectively, when compared to healthcare workers. Compared to participants with higher education, participants with elementary, secondary, and university education had reduced odds of knowledge and attitude toward AED utilization by 15.4%, 64.8%, and 37.8%, respectively. Participants who had BLS training had 2.5 times more knowledge and attitude towards utilizing AED in public when compared to non-BLS trained participants.

Table 3 Factors Influencing Respondents’ Knowledge of and Attitude Toward AED Utilization

There was a statistically significant difference in the mean KAP scores of AED use among nationality, occupation, level of education, and BLS training (p-value <0.05), but not between sexes (p-value >0.05) (Table 4).

Table 4 Comparison of KAP Scores of AED Use

Discussion

Proper and basic knowledge on the application of CPR and AEDs are life-saving skills, which are critical for all members of society to possess.¹⁵ The purpose of this study was to assess the attitude, understanding, and awareness of the use of AED among individuals in Saudi Arabia.

The Spearman rank correlation revealed that male respondents had 17% less knowledge and attitude towards using an AED than did female respondents. In a survey among students, there was no significant difference in knowledge scores between the male and female participants.¹⁶ Additionally, Kanstad and Bjorn¹⁷ reported that female students had a much higher level of dedication than male students. According to research, female students were especially interested in taking BLS classes outside the classroom if they were more widely available.

There was no discernible difference in the age between respondents who received and did not receive training on CPR/BLS. However, the Spearman rank correlation coefficient showed that with an increase in the respondents’ age (OR 1.00), their knowledge and attitude on using AEDs increased by 0.3%.

Saudi nationals’ knowledge and attitude on using an AED were low at 70.7%, when compared with foreign nationals. Statistics from a public study by Al-Turki and Yousef¹⁸ revealed that Saudi Arabia has a lower proportion of trained individuals than other nations do. This proportion suggests that to bring citizens into compliance with international standards, more attention should be paid to the necessity of training the public in utilizing AEDs and other life-saving techniques.

Our study included working adults, students, health care professionals, and non-workers. The results showed that 54.7% of students, 49.3% of employees, 96.2% of health workers, and only 32.2% of non-workers had training on CPR/BLS. Overall, 54.92% had received BLS/CPR training. According to Jarrah and Samiha,¹⁹ 29% of participants of their study received CPR training in Jordan, which is higher than the percentages reported in Hong Kong (21%)²⁰ and mainland China (25.6%)²¹ and on par with that reported in Ireland 28%²² and in New Zealand (27%).²³ Other countries have reported higher percentages of trained individuals at 58%, 75%, and 79% for Australia,²⁴ Poland,²⁵ and the United States,²⁶ respectively.

Comparing students, employees, and non-workers to healthcare workers, the probability of having knowledge and a positive attitude on using an AED were reduced by 90.1%, 88.9%, and 87.6%, respectively. Compared with higher education participants, those with elementary, secondary, and university education levels had lower probabilities of knowledge and attitude towards using AEDs by 15.4%, 64.8%, and 37.8%, respectively. Compared to those who did not receive BLS/CPR training, those who were trained had a 2.5 times greater understanding of and attitude towards using an AED in public.

According to Chair et al, people with full-time occupations and higher educational degrees were more likely to receive CPR instructions.¹⁹ In case of an emergency, those who said that they had undergone CPR training were more willing to use it at home and in public. Nevertheless, the respondents’ overall level of CPR knowledge was low. Research conducted in Nepal in 2012 revealed that medical and paramedical workers had lower average mean scores on their knowledge of resuscitation techniques.²⁷ These traits lend credence to the notion that CPR training is more likely to increase the likelihood of performing CPR.

The five main issues that our study participants experienced were as follows: 71 respondents (40% had CPR training) were terrified that one of the victims may be inadvertently wounded. Additionally, 69 respondents (39.1% had CPR training) believed that the bystander’s sole responsibility was to call the ambulance and wait for help to arrive. Of the 114 passengers who claimed that they had never been instructed on what to do, 35.9% had received CPR training. Twenty respondents (35% had CPR training) feared committing an error. A total of 218 respondents stated that they had never witnessed such a situation; among them, 52.7% were CPR trained. In a study by Jarrah,¹⁹ 23.3% of the overall participants witnessed a sudden cardiac arrest. Nearly half of the participants said that they dialed the emergency line, and the remaining participants said that they asked for assistance, applied chest compressions, and performed mouth-to-mouth breathing. Chest compressions, mouth-to-mouth breathing, and “simply watched and left” received the lowest ratings.

Familiarity with fundamental CPR procedures can increase the likelihood of a patient’s survival. The purpose of this study was to ascertain the relationship between the CPR knowledge and skills of emergency medical workers and the general public.

Although having a thorough understanding of CPR was linked to a higher likelihood of performing the tasks correctly, research by Todd²⁸ revealed that the overall performance remained subpar, which is inconsistent with our study. This sub-standard performance might be caused by the caliber of refresher courses and educational workshops, time between sessions, busy work schedules, lack of motivation or interest in the job, rarity of interactions with medical emergencies, or failure to recognize the value of maintaining CPR knowledge.²⁹

Although universities and schools play a significant role in raising awareness, media can reach a wider audience and cover a significant number of individuals. The inclusion of such straightforward training programs by qualified individuals may benefit communities and public health. Clear funding and sources of pertinent school information are required for the successful implementation of CPR training programs in school curricula. Relevant information should include who can train students in CPR, what proficiency level is necessary, what training materials are needed, where to find the resources, which grades can be trained, how often training should occur, and which curriculum components should be included.³⁰ Future studies are required to identify the best practices for implementing CPR education.

A planned reaction to cardiac emergencies will lower fatalities in educational settings and guarantee that confusion will not result in a poor or non-existent response.³¹ Moreover, Hansen³¹ underlined the need for complete explanations of all curriculum topics and the inclusion of hands-on CPR and AED practice. Despite the limitations of the study’s sample size, this study offers a comprehensive view of the topic. Additionally, there is a critical need to start monitoring cardiac arrest and raise public understanding of public health measures, such as CPR.

Conclusion

This study shows the importance of AED education in order to increase it’s usage. Practical implications are outcomes connected to or implied by putting a plan or scenario into action in the real world. We advise supporting training programs through the media, using accessible and cost-effective technologies, such as social and digital media, to reach the public. National rules such as the Good Samaritan law should also safeguard individuals who assist those in a cardiac arrest or other emergency situations.