Barriers and facilitators to global access to life-saving skills training: an international cross-sectional survey

Abstract

Introduction

Emergency care begins in the community, who are often the first on the scene. Where emergency care systems are nascent or absent, bystanders represent the only prehospital emergency care that victims might receive. It is important to equip bystanders through life-saving skills training (LST). The aim of this study was to describe access to LST for laypersons globally and to determine barriers or facilitators for access to LST globally.

Methods

A global cross-sectional, online survey was undertaken with stakeholders involved in LST programmes and policies through purposive, snowball sampling. The invitation for participation was distributed to local, regional and international emergency care and resuscitation organisations and their membership. Data were collected using a custom-designed survey, based on the literature and following pilot testing. Data were analysed descriptively and visualised according to countries and regions. Logistic regression was used to identify variables predictive of LST.

Results

A total of 302 responses from 67 countries were analysed. Majority of responses were from high- or upper-middle income countries (61.2%) compared with low- or lower-middle income countries (38.8%). All respondents from Europe reported reliable access to LST. Of respondents who reported no LST is delivered, the highest proportion of these represented the Eastern Mediterranean (18.2%), Africa (17.1%) and South America (16.9%). The most common barrier to accessing LST were cultural views surrounding LST (69.2%), while the most common facilitator was interpersonal relationships to encourage the uptake of LST (71.9%). Country level of income (adjusted OR (AOR) 4.31 (95% CI 1.62 to 11.45), p<01), urban location (AOR 10.57 (95% CI 3.32 to 33.66), p<0.001) and level of EMS development (OR 5.73 (95% CI 1.47 to 22.30), p=0.01) were predictive of access to LST.

Conclusion

This study highlights considerable inequity in LST access globally. Future work should seek to mitigate barriers and leverage facilitators through participatory and community-oriented approaches to LST.

Correspondence to Willem Stassen; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Compared with other studies on public (life-saving skills training) programmes, this survey includes a higher representation of low- to middle-income countries with participants from 67 countries.

• This study is limited by its purposive, snowball sampling approach which might have resulted in under-representation of certain contexts, especially in the most underdeveloped emergency care systems.

• This study is also limited by the lack of statistical weighting techniques to adjust for demographic imbalances across regions due to small sample sizes from certain countries.

Background

Globally, emergency medical conditions contribute to more than half of all mortality, and accounts for 42% of the global burden of disease.¹ Low- to middle-income countries (LMICs) are disproportionately affected; the burden from emergency conditions is 4.4 times higher in low-income countries when compared with higher income countries.¹ Similarly, emergency medical conditions account for 2.73 times more disability-adjusted life years lost in Africa when compared with Europe.¹

Highlighting the contribution of emergencies to poor outcomes, the 76th World Health Assembly adopted a resolution in 2023 that called for coordinated emergency, critical and operative care in order to advance universal health coverage.² The resolution calls for community engagement in the design of integrated programmes and life-saving skills training (LST), among others.² The WHO’s emergency care system framework places the bystander as the first point of contact and initiator of the emergency response when faced with a ill or injured person.³ Where formal emergency medical services (EMS) do not exist, like in many low- and LMICs or in rural areas, it is recommended that community-based, layperson first responder programmes integrate into the existing emergency care system to bolster access to life-saving interventions.⁴

It is essential for laypersons to be equipped with the necessary skills and training in order to perform initial life-saving interventions on victims, such as haemorrhage control^{5 6} and cardiopulmonary resuscitation (CPR).^{7 8} For instance, in out-of-hospital cardiac arrest (OHCA) community-based interventions such as bystander CPR and automated external defibrillator (AED) use have been associated with significant improvements in survival and neurological outcomes.⁸ Similarly, haemorrhage, one of the primary causes of death following injury,^{9 10} is often preventable through early bystander interventions.⁹ Conversely, lack of access to LST may reduce the likelihood of a bystander being able to safely and effectively perform such interventions, which may lead to delays and preventable deaths.^{7 11 12}

Despite its importance, the prevalence of LST remains low,¹³ with considerable variation and inequities across regions and contexts.^13–15 Financial cost, sociodemographic factors, lack of information on LST, difficulty in accessing training centres and older age were found to be common barriers for learning life-saving skills.^14–16 Moreover, ageing populations, shifts in disease burden, global conflicts and the impact of COVID-19-related restrictions necessitates a need for access to LST be evaluated globally.

The aim of this study was to describe access to LST for laypersons globally and to determine any barriers to or facilitators for access to LST in diverse contexts. ‘Lifesaving skills’ here, is defined as the technical, and social and cognitive skills that enable a person in a community to deliver immediate and appropriate care for victims experiencing medical emergencies from illness or injury.

Methodology

Study design

We performed a global, cross-sectional online survey. This manuscript is reported in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES)¹⁷ and Strengthening the Reporting of OBservational studies in Epidemiology checklist for cross-sectional studies.¹⁸

Study population and sampling

The target population of this survey were stakeholders involved in LST programmes and policies, including clinicians, leaders and experts from governments, industry and academia. A purposive, snowball sampling technique was employed. The survey link and flyer were distributed to a variety of local, regional and international emergency care and resuscitation organisations who were requested to forward the link to their membership and networks. The international organisations involved in dissemination of the survey included the Global Resuscitation Alliance (GRA), International Federation for Emergency Medicine (IFEM), African Federation of Emergency Medicine (AFEM), European EMS Leadership Network and WHO South Asia Chapter. All participants were required to provide informed consent prior to being directed to the survey. Participation in the survey was voluntary, and consent could be withdrawn by simply exiting the survey. No incentives were offered for participation.

Data collection instrument

Given the descriptive nature of this study, we developed a custom-designed survey (online supplemental appendix A) in order to obtain the needed data to answer the research aims and objectives. The survey was developed in three phases. The survey was first developed by one of the authors (SYJK), whereafter it was refined through regular, focused meetings by the GOALS international working group (AFWH, WS, ALB and LZ). Next, the draft survey was reviewed and approved by the principal investigators in the GOALS steering committee (MO and FL). Finally, the survey was piloted by 13 experts known to the authors from China, Ecuador, Ireland, Norway, Singapore, South Africa and the UK. Pilot participants were asked to comment on the content and test the usability and technical functionality of the survey.

The final survey consisted of 36-questions that sought to gather data on the participants demographics, the out-of-hospital emergency care system, the delivery and content, workforce, leadership and governance, and financing and sustainability of LST within the region that the participant represents. Finally, participants were asked to identify barriers and facilitators to accessing LST. The survey was translated into Chinese (by the Chinese coinvestigators) and French, Portuguese and Spanish (using the automated translation service of the survey platform, Zoho Survey).

Data collection and management

The study was hosted using the encrypted online survey platform, Zoho Survey (Zoho Corp. Pvt; Chennai, India). The survey was open for participation from 21 June 2022 to 31 October 2022. Due to low uptake, particularly from Europe (likely due to the summer vacation), the survey was opened again between 20 and 31 March 2023. Items on the survey were not randomised however, adaptive questionnaire design was used to reduce the number and complexity of the questions. No questions were mandatory. Data were exported from the Zoho Survey platform to an Excel spreadsheet (Microsoft Corp., Redmond, WA) for processing.

Survey responses were considered invalid and excluded if there were no populated fields at all or if submission was incomplete (i.e. missing answers to vital data points on LST in survey section D onwards, Appendix A). To maximise the number of valid responses, survey respondents who voluntarily left their contact details, but had missing items, were contacted via email to obtain any missing or discrepant data. Participants were given a 2 week window to reply with their responses and were reminded once via email. Collection of updated survey responses officially ended on 2 November 2023.

Data analysis

Descriptive analysis of survey participants’ demographic information and survey responses were presented as frequency distributions with percentages (calculated based on total number of respondents in each region). Aggregate results of the survey responses were categorised and reported by regions based on the WHO classification of regions (Africa, the Americas, the Eastern Mediterranean, Europe, Southeast Asia and the Western Pacific). Combined aggregate results of all respondents were also provided.

Chi-square test was used to assess for differences in the proportions of each selected response between participants from different regions. This was applied to questions on LST characteristics in the ‘Results’ section. To identify variables that were associated with an increased odds of providing LST (as reported by participants in the ‘Results’ section), we employed a multivariable logistic regression model with backward selection (threshold p<0.05). Country income, rurality (based on participants’ reported location) and level of EMS establishment (based on participants’ answers in the ‘Methodlogy’ section) were included as variables. Country income is reported in the form of gross national income level based on the country income classification for FY2024 by the World Bank. Rurality is reported using the Degree of Urbanisation method endorsed by the UN statistical commission where settlements are classified as either cities, towns or rural areas based on population densities. Low/LMICs (country income), rural areas (rurality), absence of EMS system (level of establishment of EMS) were used as reference groups for the respective bracketed variables.

Barriers to LST were defined as factors that hinder or limit access to LST, such as structural, economic, logistical or social obstacles that prevent individuals or communities from participating in or offering these programmes effectively. Conversely, facilitators to LST were defined as factors that promote or enhance public access to LST, enabling greater participation and training effectiveness among laypersons. Identification of these factors was based on review of existing literature as well as discussion between committee members of the workgroup, which consist of a panel of academic and clinical experts in prehospital emergency care and resuscitation science. Finally, barriers and facilitators were deductively stratified into individual, interpersonal, institutional, community and policy levels using the Levesque framework for healthcare access.¹⁹

Data on respondents’ geographic distribution and EMS establishment levels were visualised with shaded maps created on Microsoft Excel 365. Statistical analysis was conducted on SPSS V.29 (SPSS, Chicago, IL).

Results

A total of 394 survey responses were obtained. After removal of invalid responses, 302 responses from 67 countries were eligible for analysis. Given our recruitment and sampling strategy, it is not possible to report a response rate because the denominator is unknown. The completion rate (ratio of users who finished the survey vs users who agreed to participate) was 76.6%, while the completeness rate (how completely questionnaires were filled in) was 83.4%.¹⁷ We report in online supplemental figure S1 how the final sample was derived.

Figure 1 shows the global spatial distribution and density of survey respondents, while table 1 shows their demographics. A total of 67 countries across seven regions were represented. A detailed report of the countries represented is provided in online supplemental table S1. Most respondents were male physicians, between the ages of 30 and 59 years. Half of the survey respondents indicated that they represent regional areas (ie, city/state/province levels). Figure 2 maps the stage of development of EMS as reported by the respondents. Countries with less established EMS systems are shown in darker shades. In cases where there are different responses provided by respondents within each country, the majority response is represented on the map. If there is no majority, the response by the participant with the most complete set of survey answers is represented on the map. High-income countries (HICs) reported well or fully established EMS, while LMICs reported various stages of partial development.

Figure 1. Shaded map showing the distribution and density of survey respondents.

Figure 2. Shaded map representing the stage of establishment of prehospital emergency medical services in each country as reported by survey respondents.

Table 1

Baseline demographics of survey respondents

	All (n=302), n (%)	Africa (n=35), n (%)	North America (n=34), n (%)	South America (n=83), n (%)	Europe (n=27), n (%)	Eastern Mediterranean (n=11), n (%)	Southeast Asia (n=23), n (%)	Western Pacific (n=89), n (%)
Profession
Physician	108 (35.8)	14 (40.0)	12 (35.3)	14 (16.9)	6 (22.2)	6 (54.5)	16 (69.6)	40 (44.9)
Nurse	51 (16.9)	8 (22.9)	0 (0)	32 (38.6)	2 (38.6)	1 (9.1)	2 (8.7)	6 (6.7)
Academics*	37 (12.3)	2 (5.7)	2 (5.9)	15 (18.1)	5 (18.5)	2 (18.2)	1 (4.3)	11 (12.4)
LST instructor	34 (11.3)	5 (14.3)	5 (14.7)	9 (10.8)	1 (10.8)	0 (0)	2 (8.7)	12 (13.5)
Medical director	27 (8.9)	0 (0)	10 (29.4)	0 (0)	6 (0)	2 (18.2)	1 (4.3)	8 (9.0)
EMT/paramedic	7 (2.3)	4 (11.4)	0 (0)	0 (0)	1 (0)	0 (0)	1 (4.3)	1 (1.1)
Firefighter	4 (1.3)	0 (0)	1 (2.9)	2 (2.4)	0 (2.4)	0 (0)	0 (0)	1 (1.1)
Others†	34 (11.3)	2 (5.7)	4 (11.8)	11 (13.3)	6 (13.3)	0 (0)	0 (0)	10 (11.2)
Gender
Male	189 (62.6)	16 (45.7)	26 (76.5)	45 (54.2)	24 (88.9)	11 (100)	16 (69.6)	51 (57.3)
Female	112 (37.1)	19 (54.3)	8 (23.5)	38 (45.8)	3 (11.1)	0 (0)	7 (30.4)	37 (41.6)
Prefer not to say	1 (0.3)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	1 (1.1)
Age group
18–29	18 (6.0)	7 (20)	1 (2.9)	3 (3.6)	0 (0)	0 (0)	3 (13.0)	4 (4.5)
30–59	251 (83.1)	27 (77.1)	25 (73.5)	69 (83.1)	22 (81.5)	10 (90.9)	17 (73.9)	81 (91.0)
>60	33 (10.9)	1 (2.9)	8 (23.5)	11 (13.3)	5 (18.5)	1 (9.1)	3 (13.0)	4 (4.5)
Area of representation
National	65 (21.5)	11 (31.4)	6 (17.6)	13 (15.7)	15 (55.6)	5 (45.5)	8 (34.8)	7 (7.9)
Regional  (city/state/province)	152 (50.3)	12 (34.3)	15 (44.1)	46 (55.4)	6 (22.2)	3 (27.3)	10 (43.5)	60 (67.4)
Community/local	85 (28.1)	12 (34.3)	13 (38.2)	24 (28.9)	6 (22.2)	3 (27.3)	5 (21.7)	22 (24.7)

*Academic professions include professors, researchers and lecturers.

†Other professions include administrators/coordinators, education staff, managers, policy advisors, etc.

EMT, emergency medical technicians; LST, life-saving skills training.

Online supplemental table S2 describes the characteristics of LST in terms of the delivery models, training providers and requirements and coverage and curricula. The most reported method of training provision is by learners going to training centres (57.9%), or instructors going to learners’ locations (55.6%). Among respondents who selected ‘we do not offer/deliver LST to the public’, the highest proportion of these are seen in respondents from the Eastern Mediterranean (18.2%), followed by Africa (17.1%) and South America (16.9%). Organisations (57.0%) are most common providers for LST and most respondents report having training at least a few times a year (53.6%). Approximately half of the respondents report that there are more training centres in urban areas. However, among respondents who indicated no difference in density of training centres between urban and rural areas, the highest proportion of them are seen in European respondents (37.0%). Finally, healthcare workers are the most common target audience for LST in our survey (66.9%), followed by laypeople (54.0%) and employees at work (51.0%).

In terms of LST instructor certification requirements, 65% of survey respondents reported that instructors are required to be certified to provide training. Approximately 70% of respondents stated that there is a standardised curriculum for some or most trainings. In terms of curriculum contents, conventional CPR (69.2%), first aid (66.9%) and AED use (66.9%) are included in most training programmes globally. Notably, AED teaching is more commonly reported by respondents from Europe (74.1%), Eastern Mediterranean (81.8%), Western Pacific (78.7%) and North America (76.5%) compared with Africa (48.6%) and South America (53%).

Table 2 presents the results of the multivariate logistic regression. As compared with LMICs, HICs have four times higher odds of providing LST (adjusted OR (AOR) 4.31 (95% CI 1.62 to 11.45), p<0.01). Compared with rural contexts, cities have ten times higher odds of providing LST (AOR 10.57 (95% CI 3.32 to 33.66), p<0.001). Finally, compared with countries with no EMS established, those with a fully established EMS had an almost six-time higher odds of providing LST (OR 5.73 (95% CI 1.47 to 22.30), p=0.01).

Table 2

Variables predictive of LST

Variables	N	Crude OR	95% CI	P value	Adjusted OR*	95% CI*	P value
Gross National Income
Low/lower middle income	55	1 (ref)	–	–	1 (ref)	–	–
High/upper middle income	247	3.02	1.27 to 7.14	0.01	4.31	1.62–11.45	<0.01
Rurality				0.00			<0.001
Rural areas	36	1 (ref)	–	–	1 (ref)	–	–
Town	60	2.18	0.70 to 6.81	0.18	2.98	0.87–10.25	0.08
City	205	5.93	2.11 to 16.62	<0.001	10.57	3.32–33.66	<0.001
EMS establishment				0.03
No EMS	14	1 (ref)	–	–	–	–	–
Partially established	87	2.59	0.69 to 9.78	0.16	–	–	–
Well/fully established	138	5.73	1.47 to 22.30	0.01	–	–	–

*ORs and 95% CIs adjusted based on other variables in the table. ORs for reference groups are reflected as 1 (ref).

EMS, emergency medical services; GNI, gross national income; LST, life-saving skills training.

Table 3 presents the barriers to and facilitators for the provision of LST as reported by the respondents. Online supplemental table S3 provides a more comprehensive global overview. An indication on the importance of each barrier and facilitator is presented by colour shading based on the percentage of respondents in each region who reported the given barrier or facilitator. The most prominent barrier to access LST was reported to be related to cultural views surrounding life-saving skills (69.2%) followed individual barriers related to knowledge of the importance of LST (66.2%). Policy barriers related to regulations (65.6%) and perceptions of policy-makers on the importance of LST (65.6%) were also highly cited. These barriers remained relatively the most important across regions.

Table 3

Barriers and facilitators to LST

Barrier or facilitator	Africa (n=35), n (%)	North America (n=34), n (%)	South America (n=83), n (%)	Europe (n=27), n (%)	Eastern Mediterranean (n=11), n (%)	Southeast Asia (n=23), n (%)	Western Pacific (n=89), n (%)
Barriers to LST
Individual-level barriers
Lack of self-knowledge or education on importance of LST	26 (74.3)	23 (67.6)	52 (62.7)	16 (59.3)	8 (72.7)	17 (73.9)	58 (65.2)
Lack of individual perception/attitudes towards LST	22 (62.9)	19 (55.9)	48 (57.8)	18 (66.7)	7 (63.6)	13 (56.5)	49 (55.1)
Lack of motivation/interest in LST	21 (60.0)	23 (67.6)	49 (59.0)	18 (66.7)	8 (72.7)	14 (60.9)	53 (59.6)
Lack of knowledge on LST being offered	23 (65.7)	19 (55.9)	41 (49.4)	18 (66.7)	3 (27.3)	14 (60.9)	45 (50.6)
Financial burden	23 (65.7)	17 (50.0)	46 (55.4)	13 (48.1)	5 (45.5)	14 (60.9)	39 (43.8)
Lack of time	9 (25.7)	14 (41.2)	26 (31.3)	13 (48.1)	5 (45.5)	10 (43.5)	40 (44.9)
Other	1 (2.9)	0 (0)	0 (0)	0 (0)	0 (0)	1 (4.3)	4 (4.5)
Personal-level barriers
Lack of social culture on providing life-saving interventions	24 (68.6)	23 (67.6)	65 (78.3)	11 (40.7)	6 (54.5)	14 (60.9)	66 (74.2)
Other	1 (2.9)	0 (0)	3 (3.6)	2 (7.4)	1 (9.1)	3 (13)	3 (3.4)
Institutional-level barriers
Lack of perception/attitude of institutional leaders on LST	22 (62.9)	17 (50.0)	40 (48.2)	11 (40.7)	5 (45.5)	13 (56.5)	37 (41.6)
Lack of institutional culture to provide LST	22 (62.9)	15 (44.1)	49 (59.0)	14 (51.9)	4 (36.4)	12 (52.2)	37 (41.6)
Lack of qualified instructors	19 (54.3)	11 (32.4)	33 (39.8)	9 (33.3)	5 (45.5)	12 (52.2)	41 (46.1)
Poor quality training (only if available)	10 (28.6)	9 (26.5)	22 (26.5)	7 (25.9)	1 (9.1)	6 (26.1)	11 (12.4)
Training duration too long/short	10 (28.6)	9 (26.5)	18 (21.7)	5 (18.5)	2 (18.2)	5 (21.7)	21 (23.6)
Other	0 (0)	1 (2.9)	6 (7.2)	1 (3.7)	0 (0)	3 (13.0)	7 (7.9)
Community-level barriers
Lack of community funding	24 (68.6)	20 (58.8)	48 (57.8)	13 (48.1)	8 (72.7)	16 (69.6)	54 (60.7)
Lack of community leadership	18 (51.4)	19 (55.9)	43 (51.8)	18 (66.7)	8 (72.7)	15 (65.2)	38 (42.7)
Lack of community capacity	14 (40.0)	10 (29.4)	30 (36.1)	6 (22.2)	6 (54.5)	13 (56.5)	40 (44.9)
Lack of dissemination of information on LST	23 (65.7)	20 (58.8)	60 (72.3)	11 (40.7)	5 (45.5)	15 (65.2)	47 (52.8)
Low incidence of CA/CVD	3 (8.6)	4 (11.8)	6 (7.2)	0 (0)	1 (9.1)	1 (4.3)	7 (7.9)
Other	0 (0)	1 (2.9)	1 (1.2)	0 (0)	0 (0)	1 (4.3)	2 (2.2)
Policy-level barriers
Lack of policies/regulations that promote LST	24 (68.6)	23 (67.6)	63 (75.9)	13 (48.1)	7 (63.6)	17 (73.9)	51 (57.3)
Lack of perception/attitudes of policymakers	25 (71.4)	20 (58.8)	60 (72.3)	15 (55.6)	6 (54.5)	17 (73.9)	55 (61.8)
Other	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
Facilitators to LST
Individual-level facilitators
High self-knowledge or education on importance of LST	28 (80.0)	22 (64.7)	60 (72.3)	19 (70.4)	8 (72.7)	17 (73.9)	53 (59.6)
High individual perception/attitude towards LST	21 (60.0)	18 (52.9)	50 (60.2)	18 (66.7)	6 (54.5)	15 (65.2)	50 (56.2)
High individual motivation/interest in LST	24 (68.6)	22 (64.7)	57 (68.7)	17 (63.0)	7 (63.6)	17 (73.9)	50 (56.2)
Good knowledge/information on LST offered	25 (71.4)	18 (52.9)	47 (56.6)	16 (59.3)	6 (54.5)	12 (52.2)	46 (51.7)
No financial burden	20 (57.1)	17 (50.0)	40 (48.2)	18 (66.7)	5 (45.5)	12 (52.2)	42 (47.2)
Economic incentives (eg, no/low fees, gifts)	20 (57.1)	18 (52.9)	43 (51.8)	13 (48.1)	6 (54.5)	13 (56.5)	41 (46.1)
Compulsory	19 (54.3)	13 (38.2)	27 (32.5)	13 (48.1)	4 (36.4)	13 (56.5)	35 (39.3)
Other	1 (2.9)	0 (0)	0 (0)	0 (0)	0 (0)	1 (4.3)	3 (3.4)
Interpersonal-level facilitators
Strong social culture on providing life-saving interventions	23 (65.7)	18 (52.9)	52 (62.7)	19 (70.4)	7 (63.6)	13 (56.5)	54 (60.7)
Encouragement of taking up LST	27 (77.1)	23 (67.6)	65 (78.3)	18 (66.7)	7 (63.6)	18 (78.3)	59 (66.3)
Other	0 (0)	1 (2.9)	1 (1.2)	1 (3.7)	1 (9.1)	0 (0)	2 (2.2)
Institutional-level facilitators
Strong perception/attitude of institutional leaders on LST	24 (68.6)	19 (55.9)	51 (61.4)	21 (77.8)	7 (63.6)	17 (73.9)	53 (59.6)
Strong institutional culture to provide LST	27 (77.1)	22 (64.7)	60 (72.3)	17 (63.0)	6 (54.5)	16 (69.6)	55 (61.8)
Sufficient supply of qualified instructors	23 (65.7)	14 (41.2)	48 (57.8)	12 (44.4)	5 (45.5)	16 (69.6)	44 (49.4)
High-quality training	21 (60.0)	18 (52.9)	53 (63.9)	14 (51.9)	5 (45.5)	15 (65.2)	49 (55.1)
Other	1 (2.9)	1 (2.9)	2 (2.4)	1 (3.7)	0 (0)	0 (0)	1 (1.1)
Community-level facilitators
Adequate community funding	20 (57.1)	20 (58.8)	42 (50.6)	12 (44.4)	7 (63.6)	14 (60.9)	48 (53.9)
Strong community leadership	23 (65.7)	19 (55.9)	43 (51.8)	19 (70.4)	8 (72.7)	16 (69.6)	48 (53.9)
Adequate community capacity	17 (48.6)	15 (44.1)	37 (44.6)	10 (37.0)	7 (63.6)	10 (43.5)	39 (43.8)
Extensive advertising of LST	20 (57.1)	20 (58.8)	57 (68.7)	14 (51.9)	6 (54.5)	18 (78.3)	51 (57.3)
High incidence of CA/CVD	7 (20)	5 (14.7)	24 (28.9)	3 (11.1)	3 (27.3)	6 (26.1)	23 (25.8)
Other	1 (2.9)	1 (2.9)	2 (2.4)	0 (0)	0 (0)	0 (0)	4 (4.5)
Policy-level facilitators
Strong policy/regulations that promote LST	26 (74.3)	20 (58.8)	59 (71.1)	17 (63.0)	8 (72.7)	18 (78.3)	54 (60.7)
Strong perception/attitudes of policymakers	19 (54.3)	21 (61.8)	56 (67.5)	17 (63.0)	6 (54.5)	17 (73.9)	54 (60.7)
Other	1 (2.9)	1 (2.9)	4 (4.8)	0 (0)	0 (0)	0 (0)	3 (3.4)

CA, cardiac arrest; CVD, cardiovascular disease; LST, life-saving skills training.

Similarly, the most cited facilitators to accessing LST again rested on the interpersonal relationships to encourage the uptake of life-saving skills (71.9%) or individuals to have self-knowledge of the importance of LST (68.5%). This was followed by the institutional culture within a given context to support LST (67.2%) and the regulatory and policy environment to mandate LST (66.9%). Again, these facilities remained relatively stable across regions. One opportunity might be the use of advertising to promote LST, which was identified as an important barrier in Southeast Asia (78.3%).

Barriers and facilitators were deductively categorised in figure 3, based on the Levesque framework for healthcare access,¹⁹ which we have modified to describe factors that influence access to health-related training services such as LST. Factors that exist at the systems level are shown in the upper panel, whereas factors at the individual level are shown in the lower panel.

Figure 3. Barriers and facilitators to LST. LST, life-saving skills training.

Discussion

This study sought to describe the global status of public access to LST and, where access exists, the characteristics of the LST. We further sought to determine the perceived barriers to and facilitators for accessing LST globally. To the best of our knowledge, this is the first and largest of such global surveys with good representation from LMICs. There is considerable variability in LST access globally, with poor access specifically in the African, South American, Eastern Mediterranean and Southeast Asian regions. It was found that access to LST was influenced by the level of development of the EMS system, rurality and country level of income. Respondents from settings that were more rural, those with less developed EMS and from LMICs had the lowest access to LST.

These findings are similar to a recent systematic review that revealed geographic variation in the prevalence of bystander CPR and AED training across the globe. While there was a paucity of published literature from LMICs, where data existed, it consistently showed lower training prevalences.¹³ One reason for this may be due to limited fiscal space amid competing burden of disease priorities, especially considering that LST programmes directed only at mass public CPR campaigns may fall outside of cost-effectiveness thresholds for many LMICs.^20–22 It is therefore recommended that LST encompass multiple emergency medical conditions that may be amenable to early bystander intervention. Funding agencies should also preferentially support programmes in LMICs to urgently reduce these disparities. However, funding priorities, goals and success criteria should be codeveloped through ongoing engagement to ensure alignment with local needs and to establish equitable partnerships. Similar approaches may be employed to address rural and urban disparities within a particular country or region.

Communities play an important role in bringing emergency care to where patients need it, especially in nascent emergency care systems or rural parts of developed systems. This may be in the form of early recognition and transport to healthcare establishments, rescue from structural collapse or similar disasters²³ or the provision of time-sensitive, proven interventions such as CPR^{7 8} or haemorrhage control.^{5 6} A Tanzanian study found that among police officers who underwent LST, almost half reported having provided haemorrhage control within the first 6 months following training.⁵ Similarly, in a Ugandan study, 97% of trainees used their life-saving skills by 6 months, most commonly haemorrhage control.⁶

Community LST and first-aid responder programmes have been implemented in many regions and contexts across the world with demonstrable impact on sharp-end clinical outcomes. The implementation of bystander CPR training, for example, has been shown to increase the odds of survival with good neurological outcome by between 60% (OR 1.59 (1.20–2.10))⁸ and 95% (OR 1.95 (1.66–2.30)).⁷ Further, in victims of non-fatal injury, receiving first aid from a provider trained in life-saving skills increased the odds of recovery or clinical improvement when compared with receiving care from a non-trained provider (OR 1.28 (1.02–1.61)). There was also no significant differences between the outcomes of victims who received no first aid compared with those who received first aid from an untrained provider.¹² In an earlier study, providing LST for injuries to laypersons in a village community in rural Cambodia and Northern Iraq resulted in a mortality decrease of 9% (95% CI 1.8% to 16.0%).²⁴ This illustrates the importance of good quality and contextually relevant LST to maximise impact. As such, it is imperative that nascent and well-developed emergency care systems should actively address barriers to LST and leverage on facilitators to increase public access to LST. This will help maximise public LST training rates and increase the likelihood that trained individuals are nearby when emergencies occur. LST in itself has also been demonstrated to increase bystander willingness²⁵ and propensity to act in case of an emergency.^{26 27}

The most important barriers and facilitators reported by respondents related to individual and sociocultural or community factors, followed by policy or regulatory barriers and facilitators. This is similar to findings from other studies conducted in the USA¹⁶ and China.²⁸ The prominence of sociocultural views and beliefs, including at individual level, suggest that it is vital for LST programmes and interventions to be tailored and relevant to the sociocultural and epidemiological context in which they are to be implemented. This necessitates that they be cocreated through community engagement to ensure relevance, acceptability and cultural sensitivity. This may foster a sense of ownership and ensure self-sustainability by leveraging local resources and being responsive to the evolving needs of the community.²⁹ This should be accompanied by the establishment of appropriate community-based metrics and success criteria to ensure for adequate monitoring and evaluation. Individual barriers may also be overcome through the use of media and advertising to create awareness of the importance of LST, which was a prominent facilitator in the Southeast Asian regions. Mass media campaigns have been used successfully to improve knowledge of and willingness to perform basic life support following cardiac arrest,^{30 31} and to influence the recognition of acute coronary syndrome, shortening time from symptom onset to presentation.³²

The parallel prominence of the policy environment, both in terms of barriers and facilitators, illustrates the key role that political and regulatory frameworks play in LST dissemination and enforcement. There is an urgent need for clinicians and civil society to lobby policy-makers towards policy reform. This may be through the drafting and promulgation of bills related to mandatory or subsidised LST through the workplace or within the school curriculum.

Finally, LST should be sensitive to downstream health resources available in a particular healthcare system and focus on cost-effective, impactful interventions. As demonstrated in Uganda, a 1 day LST course on trauma seems to be cost-effective at $25–$75 per life-year saved.⁶ By exploiting technology to improve the reach and accessibility of LST, this cost may be driven down significantly. Using online-only instruction has been shown to be equivalent to standard in-person instruction when applied to basic life support and CPR training.^{33 34} Future work should seek to determine how this can be adapted to other LSTs.

Limitations

This study has a few limitations. First, due to the study design and snowball sampling approach, it was not possible to report the exact response rates, making it impossible to assess for non-response bias. It is theoretically more likely that those settings that do not have access to LST would be less likely to respond. As such, the preponderance of high or upper middle-income countries among respondents may have overestimated the global prevalence of LST. Deploying a global survey at the right time is crucial in optimising the response rate so that it may account for public holidays and vacation periods, religious observances and other cultural activities. While attempts were made to minimise the impact of this on our response rates by providing multiple opportunities to complete the survey, this might explain why certain countries had small sample sizes of respondents. The inherent limitations of a relatively small sample size also prevented us from applying statistical weighing techniques to adjust for demographic imbalances across regions. Finally, due to the self-reported nature of our survey, response bias may affect the validity of the results. Nonetheless, our findings still provide valuable insights into the perspectives of a diverse pool of crucial LST stakeholders worldwide. The primary focus of our survey centres on exploring specific themes and trends on LST rather than making population-level inferences. Moreover, our analysis is geared towards exploring patterns within the available data rather than making broad extrapolations to the entire global population. Compared with previous studies, our survey also contains a higher representation of LMICs, with 25 out of 67 participating countries (37.3%) classified as low or lower-middle income. Therefore, while acknowledging the limitation of representativeness, the responses collected remain meaningful for addressing the specific research gaps. We believe this is an important turning point towards more directed research into public access to LST. Future steps to systematically investigate means to overcome barriers and implement community programmes in collaboration with local LST stakeholders in each region may be helpful in improving public access to LST.

Conclusion

This study highlights considerable inequity in LST access globally, with higher-income urban contexts with developed EMS reporting greater access to LST. Future work should seek to mitigate against barriers and leverage facilitators through participatory and community-oriented approach. These programmes should be comprehensive to address the specific needs of the context and its burden of disease, be sensitive to sociocultural and resourcing factors. For this, additional in-country epidemiological, community-based and system-orientated research may be warranted to inform decision.

We would like to acknowledge members of the Global Resuscitation Alliance (GRA), International Federation for Emergency Medicine (IFEM) and African Federation of Emergency Medicine (AFEM) for piloting of the survey.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants. The study was approved by the Human Research Ethics Committee of the University of Cape Town (HREC Ref. 072/2022). Participants gave informed consent to participate in the study before taking part.

Footnote

X @willem_stassen

Contributors WS: conceptualisation, methodology, writing—original draft, writing —review and editing; CYL: formal analysis, writing—original draft, writing—review and editing; ALB and LZ: conceptualisation, methodology, writing—review and editing; SYJK: conceptualisation, methodology, project administration, writing—review and editing; FL and MO: conceptualisation, writing—review and editing, supervision; AFWH: conceptualisation, methodology, formal analysis, writing—review and editing. The first author, WS, is the guarantor.

Funding This study received no specific funding. Article processing charges are supported by the University of Cape Town.

Map disclaimer The inclusion of any map (including the depiction of any boundaries there), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

References

¹ Razzak J, Usmani MF, Bhutta ZA. Global, regional and national burden of emergency medical diseases using specific emergency disease indicators: analysis of the 2015 Global Burden of Disease Study. BMJ Glob Health 2019; 4: e000733. doi:10.1136/bmjgh-2018-000733

² Geneva, Switzerland:; World Health Organization (WHO). Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies, May 2023. Available: https://apps.who.int/gb/ebwha/pdf_files/WHA76/A76_R2-en.pdf

³ Reynolds T, Sawe H, Rubiano A, et al. Strengthening health systems to provide emergency care. In: Jamison D, Gelband H, Horton S, et al., eds. Disease control priorities: improving health and reducing poverty. Washington (DC): The International Bank for Reconstruction and Development / The World BankWordl Bank, 2017.

⁴ Diango K, Mafuta E, Wallis LA, et al. Implementation and evaluation of a pilot WHO community first aid responder training in Kinshasa, DR Congo: A mixed method study. Afr J Emerg Med 2023; 13: 258–64. doi:10.1016/j.afjem.2023.09.001

⁵ Ndile ML, Lukumay GG, Bolenius K, et al. Impact of a postcrash first aid educational program on knowledge, perceived skills confidence, and skills utilization among traffic police officers: a single-arm before-after intervention study. BMC Emerg Med 2020; 20: 21. doi:10.1186/s12873-020-00317-y

⁶ Jayaraman S, Mabweijano JR, Lipnick MS, et al. First Things First: Effectiveness and Scalability of a Basic Prehospital Trauma Care Program for Lay First-Responders in Kampala, Uganda. PLoS ONE 2009; 4: e6955. doi:10.1371/journal.pone.0006955

⁷ Song J, Guo W, Lu X, et al. The effect of bystander cardiopulmonary resuscitation on the survival of out-of-hospital cardiac arrests: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2018; 26: 86. doi:10.1186/s13049-018-0552-8

⁸ Simmons KM, McIsaac SM, Ohle R. Impact of community-based interventions on out-of-hospital cardiac arrest outcomes: a systematic review and meta-analysis. Sci Rep 2023; 13: 10231. doi:10.1038/s41598-023-35735-y

⁹ Jones AR, Miller J, Brown M. Epidemiology of Trauma-Related Hemorrhage and Time to Definitive Care Across North America: Making the Case for Bleeding Control Education. Prehosp Disaster Med 2023; 38: 780–3. doi:10.1017/S1049023X23006428

¹⁰ Eastridge BJ, Holcomb JB, Shackelford S. Outcomes of traumatic hemorrhagic shock and the epidemiology of preventable death from injury. Transfusion 2019; 59: 1423–8. doi:10.1111/trf.15161

¹¹ Hossain MJ, Hossain MS, Mayaboti CA, et al. Impact of community-based first responder development for the management of drowning casualties in rural areas of Bangladesh. Afr J Emerg Med 2020; 10: 219–23. doi:10.1016/j.afjem.2020.07.009

¹² Hoque DME, Islam MI, Sharmin Salam S, et al. Impact of First Aid on Treatment Outcomes for Non-Fatal Injuries in Rural Bangladesh: Findings from an Injury and Demographic Census. Int J Environ Res Public Health 2017; 14: 762. doi:10.3390/ijerph14070762

¹³ Ng TP, Eng SW-O, Ting JXR, et al. Global prevalence of basic life support training: A systematic review and meta-analysis. Resuscitation 2023; 186:: S0300-9572(23)00084-9. doi:10.1016/j.resuscitation.2023.109771

¹⁴ Blewer AL, Ibrahim SA, Leary M, et al. Cardiopulmonary Resuscitation Training Disparities in the United States. J Am Heart Assoc 2017; 6: e006124. doi:10.1161/JAHA.117.006124

¹⁵ Abdulhay NM, Totolos K, McGovern S, et al. Socioeconomic disparities in layperson CPR training within a large U.S. city. Resuscitation 2019; 141: 13–8: S0300-9572(19)30211-4. doi:10.1016/j.resuscitation.2019.05.038

¹⁶ Sasson C, Haukoos JS, Bond C, et al. Barriers and facilitators to learning and performing cardiopulmonary resuscitation in neighborhoods with low bystander cardiopulmonary resuscitation prevalence and high rates of cardiac arrest in Columbus, OH. Circ Cardiovasc Qual Outcomes 2013; 6: 550–8. doi:10.1161/CIRCOUTCOMES.111.000097

¹⁷ Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004; 6: e34. doi:10.2196/jmir.6.3.e34

¹⁸ von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. PLoS Med 2007; 4: e296. doi:10.1371/journal.pmed.0040296

¹⁹ Levesque J-F, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013; 12: 18. doi:10.1186/1475-9276-12-18

²⁰ Pichon-Riviere A, Drummond M, Palacios A, et al. Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures. Lancet Glob Health 2023; 11: e833–42: S2214-109X(23)00162-6. doi:10.1016/S2214-109X(23)00162-6

²¹ Bouland AJ, Risko N, Lawner BJ, et al. The Price of a Helping Hand: Modeling the Outcomes and Costs of Bystander CPR. Prehosp Emerg Care 2015; 19: 524–34. doi:10.3109/10903127.2014.995844

²² Nichol G, Huszti E, Birnbaum A, et al. Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest. Ann Emerg Med 2009; 54: 226–35. doi:10.1016/j.annemergmed.2009.01.021

²³ Rom A, Kelman I. Search without rescue? Evaluating the international search and rescue response to earthquake disasters. BMJ Glob Health 2020; 5: e002398. doi:10.1136/bmjgh-2020-002398

²⁴ Husum H, Gilbert M, Wisborg T. Training pre-hospital trauma care in low-income countries: the “Village University” experience. Med Teach 2003; 25: 142–8. doi:10.1080/0142159031000092526

²⁵ Kulnik ST, Halter M, Hilton A, et al. Confidence and willingness among laypersons in the UK to act in a head injury situation: a qualitative focus group study. BMJ Open 2019; 9: e033531. doi:10.1136/bmjopen-2019-033531

²⁶ Muise J, Oliver E, Newell P, et al. Improving individuals’ propensity to act in a medical emergency: A quasi-randomised trial to test the impact of a learning intervention. Health Educ J 2019; 78: 214–25. doi:10.1177/0017896918796030

²⁷ Oliver E, Cooper J, McKinney D. Can first aid training encourage individuals’ propensity to act in an emergency situation? A pilot study. Emerg Med J 2014; 31: 518–20. doi:10.1136/emermed-2012-202191

²⁸ Dong X, Kong SYJ, Xu H, et al. “Needed but lacked”: Exploring demand- and supply-side determinants of access to cardiopulmonary resuscitation training for the lay public in China. Front Public Health 2023; 11: 1164744. doi:10.3389/fpubh.2023.1164744

²⁹ Slingers M, De Vos S, Sun JH. Ten years of the community-based emergency first aid responder (EFAR) system in the Western Cape of South Africa: What has happened, what has changed, and what has been learned. Afr J Emerg Med 2022; 12: 299–306. doi:10.1016/j.afjem.2022.06.007

³⁰ Bull S, Shadwell J, Stewart B, et al. Mass media marketing and willingness to undertake cardiopulmonary resuscitation: a cross-sectional survey of the general public in Birmingham, UK. The Lancet 2013; 382: S27. doi:10.1016/S0140-6736(13)62452-6

³¹ Orlob S, Grundner S, Wittig J, et al. Assessing the weak links–Necessity and impact of regional cardiac arrest awareness campaigns for laypersons. Resuscitation Plus 2023; 13: 100352.

³² Bray JE, Stub D, Ngu P, et al. Mass Media Campaigns’ Influence on Prehospital Behavior for Acute Coronary Syndromes: An Evaluation of the Australian Heart Foundation’s Warning Signs Campaign. J Am Heart Assoc 2015; 4: e001927. doi:10.1161/JAHA.115.001927

³³ Ali DM, Hisam B, Shaukat N, et al. Cardiopulmonary resuscitation (CPR) training strategies in the times of COVID-19: a systematic literature review comparing different training methodologies. Scand J Trauma Resusc Emerg Med 2021; 29: 53.

³⁴ Chong KM, Yang H-W, He H-C, et al. The Effectiveness of Online-Only Blended Cardiopulmonary Resuscitation Training: Static-Group Comparison Study. J Med Internet Res 2023; 25: e42325.