Barriers to automated external defibrillator use among urban residents in Khon Kaen, Thailand: A cross-sectional survey

Barriers to automated external defibrillator use among urban residents in Khon Kaen, Thailand: A cross-sectional survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers to automated external defibrillator use among urban residents in Khon Kaen, Thailand: A cross-sectional survey S Pudjapo, M Buranasakda This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7580807/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Automated external defibrillators (AEDs) can improve survival rates in individuals experiencing cardiac arrest; however, their widespread use in Khon Kaen, Thailand, is limited. We aimed to understand why this life-saving technology is not being effectively utilized in the city. Methods We conducted a cross-sectional survey among residents of Khon Kaen using a structured questionnaire with both closed- and open-ended items. Closed-ended survey responses were analyzed descriptively, while open-ended responses underwent content analysis to identify major themes. Findings from both components were then integrated to provide a comprehensive understanding of barriers to AED use. Results Of 370 respondents, approximately half were willing to use an AED during cardiac arrest. However, with telephone-assisted cardiopulmonary resuscitation (CPR), the willingness to perform CPR and use an AED increased to 71%. A major barrier was the small number of trained individuals in the city (10.5%). The second significant barrier was the misunderstanding that only trained individuals are permitted to use AEDs. Respondents perceived training in CPR and AED use as essential for providing the necessary knowledge and courage, as well as authorizing and obligating them to use AEDs in real-life situations. Conclusions This study revealed that the willingness of Khon Kaen residents to use AEDs is hindered by a lack of training and misconceptions that only trained individuals can use them. Public education and training programs, along with promotion of telephone-assisted CPR, could enhance bystander response and improve AED use. automatic external defibrillator out-of-hospital cardiac arrest cardiac arrest cardiopulmonary resuscitation emergency medical services Background Sudden cardiac arrest was once considered futile. However, over the past two decades, a robust prehospital system has considerably improved survival rates [ 1 ]. Immediate assistance with chest compressions can increase the survival rate by 2–3 times [ 2 ], and when combined with an automated external defibrillator (AED), the survival rate can reach up to 70% [ 3 ]. The effectiveness of bystander defibrillation is apparent, with the number needed to treat (NNT) being 6 for 30-day survival, compared to 112 for adrenaline [ 4 , 5 ]. In Khon Kaen city, Thailand, with a population of nearly 500,000, approximately 200 cases of out-of-hospital cardiac arrest are recorded annually. Despite having over 60 serviceable AEDs in the city, less than 10 cases per year over the past 5 years have involved bystander defibrillation prior to the arrival of emergency medical services (EMS). Globally, the use of AEDs in real-world cardiac arrest situations is similarly low. Common issues include a lack of public awareness about the existence and locations of AEDs [ 6 ], insufficient training [ 7 ], and the public's reluctance to use AEDs due to fear of harm or legal repercussions [ 8 ]. Cultural factors, such as reluctance to touch strangers and intervene in emergency situations, also play an important role [ 7 ]. In Thailand, initiatives to teach basic life support in schools and universities and to train community volunteers are in place. However, AED use in cardiac arrest cases in Khon Kaen remains limited. To date, research examining the impediments to AED deployment in Khon Kaen or similar mid-sized urban regions in Thailand remains limited. Although previous Thai studies have primarily focused on general CPR awareness or EMS efficiency, they have not addressed the specific challenges associated with AED usage in localized settings. Therefore, in order to bridge this knowledge gap, we conducted a survey to understand why this life-saving technology is not being effectively utilized in the city. Methods Study design and setting This cross-sectional survey was conducted to explore possible barriers to AED use among Khon Kaen residents. Data were collected using open- and closed-ended questionnaires between July 1 and August 31, 2023. The manuscript was prepared in accordance with the Consensus-based Checklist for Reporting of Survey Studies (CROSS) (Supplementary File 1). Participants The study targeted volunteers aged > 18 years living in Khon Kaen city. Medical personnel were excluded to focus on the general public's perspective. Sampling of participants The sample size for the study was calculated using a population proportion formula based on the 2020 population of Khon Kaen city. Using a 95% confidence level, a 5% margin of error, and an expected proportion of 50% (a conservative estimate in the absence of prior data), the required sample size was determined to be 385. Data of 387 participants, including 178 web-based and 209 paper-based questionnaire respondents, were successfully collected. After data cleaning, 370 responses were included in the final analysis. For narrative comments, sample size considerations are often guided by the principle of data saturation, which in grounded theory studies is typically reached with 20–30 participants [ 9 , 10 ]. For written responses or open-ended survey items, however, no formal sample size guidelines exist. In this study, 205 narrative responses were obtained, which allowed for a robust thematic analysis of perceived barriers to AED use. Outcomes The primary objective was to identify barriers and challenges to AED use in Khon Kaen city. The primary outcome was the willingness to use an AED during cardiac arrest. Key predictors included previous CPR and AED training, self-reported confidence in using an AED, knowledge and awareness of AEDs, and willingness to perform CPR, including willingness to use an AED under telephone assistance. Demographic characteristics (age, sex, education, occupation, and religion) were collected as covariates. In addition, open-ended responses explored perceived motivations and barriers to AED use, which were analyzed qualitatively to identify themes. Data collection The questionnaire was developed based on previous studies, the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, and the 2021 European Resuscitation Council Guidelines as references (Supplementary File 2). Before implementation, it underwent pilot testing with six participants to assess clarity, comprehension, and item flow items. Minor wording and usability adjustments were made based on their feedback. The finalized questionnaire was distributed in both online (via Google Forms) and paper formats through social media (Facebook: Khon Kaen and KKU group) and in public locations such as markets, parks, shopping malls, food courts, and university cafeterias. Data analysis Closed-ended survey response analysis All responses were entered in Excel. Nominal and ordinal data are presented as frequency and percentage, respectively. Chi-squared test was used to identify significant differences between categorical variables and explore relationships affecting AED use. Scale data were tested for normality; they are presented as mean and standard deviation. Statistical analyses were performed using SPSS software (IBM SPSS for Windows, Version 26). Open-ended survey response analysis Narrative comments from both paper-based and online questionnaires were transcribed into Microsoft Word. Two researchers independently reviewed transcripts to ensure accuracy. Content analysis was used to maintain the natural meaning of the responses. The analysis followed an inductive approach, involving systematic condensation of data into initial codes, which were then divided into broader categories. These categories were further refined to identify overarching themes. Disagreements in coding were resolved through discussions between the researchers until a consensus was reached. This systematic process ensured that the natural state of the data was preserved and minimized researcher bias. Consensus among researchers confirmed that they had identified all significant patterns in the data set. Integration of findings The results of both closed- and open-ended analyses were integrated to provide a comprehensive understanding of the barriers and challenges associated with AED use in Khon Kaen. Results Closed-ended survey results A total of 387 volunteers participated in the survey, of whom 209 responded to the paper-based survey and 178 responded to the online survey. Seventeen respondents did not complete the survey or meet the study criteria, resulting in 370 volunteers being included in the study. The majority of respondents were female individuals (65.9%). Overall, nearly one-third (32.9%) of the participants were university students. While 70% of the volunteers had heard about CPR, only 26.2% had received CPR training, and 10.5% had received AED training (Table 1). Table 1 : Characteristics of the study population (N=370) Characteristics Number (%) N=370 Sex Female 244(65.9) Age 18–30 31–50 > 51 176(47.6) 98(26.5) 96(25.9) Occupation University student Government section Others 122(32.9) 56(15.1) 192(52) Religious Affiliation Buddhism Others 351(94.9) 19(5.1) Education Level High school and under Bachelor's degree Others 138(37.3) 173(46.8) 59(15.9) Heard about CPR 262(70.8) Underwent Previous CPR Training 97(26.2) Underwent AED Training 39(10.5) Confidence to use AED 49(13.2) CPR, cardiopulmonary resuscitation; AED, automated external defibrillator Here, 54% of volunteers were willing to perform CPR on patients with out-of-hospital cardiac arrest, whereas 50% were willing to perform CPR and use an AED. If medical personnel provided assistance over the phone, the willingness to use AED increased to 71% (Table 2). On analyzing factors influencing the willingness to use an AEDs, volunteers familiar with or aware of AEDs were more willing to use them in patients experiencing out-of-hospital cardiac arrest than those who were not familiar (53.9% vs. 18.0%, p=0.008). Additionally, volunteers trained in AED use (46.2%) or who knew how to use the device (61.3%) were significantly more willing to use it (p<0.001 for both) (Table 3). Table 2. Willingness to perform CPR and use an AED among respondents Willingness Number (%) Willingness to perform CPR Willingness to perform CPR and use AED Willingness to perform CPR and use AED under telephone assistance Willingness to attend first aid and AED use training 201(54.3) 184(49.7) 263(71.1) 265(71.6) CPR, cardiopulmonary resuscitation; AED, automated external defibrillator Table 3 . Willingness to use an AED among respondents (N=370) Category Number N=370 Willing to use AED Not willing Unsure P value Have heard about AED 206(55.7) 34(18.0) 111(53.9) 58(28.2) 0.008 Have seen an AED 113(30.5) 19(16.8) 61(54.0) 33(29.2) 0.385 Know what an AED is used for 87(23.5) 21(24.1) 41(47.1) 25(28.7) 0.003 Have undergone AED training 39(10.5) 18(46.2) 13(33.3) 8(20.5) <0.001 Know how to use an AED 31(8.4) 19(61.3) 7(22.6) 5(16.1) <0.001 AED, automated external defibrillator Drawing from barriers to AED use previously identified in the literature, we categorized these barriers into three levels: strong, moderate, and mild. Most barriers were perceived as mild to moderate rather than strong. Lack of knowledge was identified as a notable concern, with 24.7% of respondents rating it as a strong barrier and 34.2% as a moderate barrier. Fear of litigation was reported by 29.5% of respondents as a strong barrier and by 34.7% as a moderate barrier. Fear of physical contact with strangers was predominantly moderate (41.9%) to mild (42.9%). Gender-related concerns were present but less prominent. Exposure of the chest area to attach an AED was mostly a mild concern, with 63.9% rating it as such for women and 51.5% for men. Technical concerns, such as fear of electric shock, were predominantly mild (50.3%) to moderate (36.4%) (Table 4). Table 4. Identified barriers to AED use among respondents Barriers Respondents (n) Strong (%) Moderate (%) Mild (%) Lack of knowledge 295 73(24.7) 101(34.2) 121(41) Fear of physical contact with a stranger 305 46(15.0) 128(41.9) 131(42.9) Fear of disease contraction 308 50(16.2) 109(35.4) 149(48.4) Fear of the opposite sex 307 36(11.7) 95(30.9) 176(57.3) Fear of exposing the chest area while attaching the AED in women 308 37(12.0) 74(24.0) 197(63.9) Fear of exposing the chest area while attaching the AED in the opposite sex 307 43(14.0) 106(34.5) 158(51.5) Fear of causing harm to a victim 308 73(23.7) 121(39.3) 114(37.0) Fear of electric shock 308 41(13.3) 112(36.4) 155(50.3) Fear of litigation 308 91(29.5) 107(34.7) 110(35.7) AED, automated external defibrillator Regarding the reasons why volunteers wanted or did not want to participate in CPR and AED training, those who wanted to participate did so to gain additional knowledge, prepare for emergencies, and help others or family members. Some volunteers wanted to attend training sessions to refresh their knowledge and ensure they follow correct procedures. In contrast, those who did not want to participate in CPR and AED training cited various reasons, including inconvenience and lack of time. Two volunteers mentioned that they could learn from the internet without attending classroom training. Two others cited age, and one volunteer cited poor health as reasons for not participating. Additionally, one volunteer did not want to attend training because of fear of blood. Open-ended survey results The analysis of open-ended survey responses from 205 participants highlighted three key themes surrounding barriers to AED use in Khon Kaen. First, motivation to help emerged as a strong driver, with participants expressing humanitarian values, a sense of moral duty, and altruism as reasons for assisting in emergencies. Second, the perception that AEDs are designed only for trained persons or professional use revealed a lack of confidence and knowledge, along with the belief that only medical professionals should handle AEDs. Third, fear of using an AED underscored concerns about causing harm, personal safety, and potential legal repercussions. Together, these themes illustrate both the willingness and hesitations of bystanders, offering insights into strategies to improve AED use in emergencies (Table 5; additional illustrative quotes are available in Supplementary File 3). Table 5. Themes, categories, and codes identified from the analysis of open-ended survey responses on barriers to AED use in Khon Kaen City. Themes Category Code Motivation to help Desire for the patient's survival Humanitarian values and compassion (feeling sorry for the patients) Altruism (want to/desire to help) A sense of moral obligation Moral imperative Cultural norms and Buddhist teachings To gain merit (Boon) Perception that AEDs are designed only for trained persons or professional use Need for AED training Lack of knowledge and confidence Previous training provides confidence and a sense of authority in using an AED Belief in the need for certification or formal training Reserved for doctors or medical staff Only doctors or medical staffs should do it Fear to use AED Fear of further harm to patients - Fear of causing more harm Fear of harm to self - Fear for one’s own safety Fear of litigation - Fear of legal responsibility for the patient’s outcome AED, automated external defibrillator Motivation to help When participants were asked about their willingness to provide CPR and use AEDs for patients with out-of-hospital cardiac arrest, many expressed a strong willingness to help. The primary motivations cited were a desire for patient survival and a profound sense of moral obligation. Many participants viewed their willingness to help as driven by humanitarian reasons. “I feel sorry for fellow human beings” #107 “Our sense of humanity doesn't allow us to stand by and let a fellow human die right in front of us 😊😊” #65 Sixty participants expressed their willingness to help out of altruism, and they were willing to intervene because they get to help patients. “I want to help” #183 “You can be a hero too!!!!” #167 Ten participants viewed providing CPR as a basic duty, moral imperative, or necessary action: “Saving lives is the right thing to do” #34 Four participants believed that performing CPR and using AED means helping others and that it is merit-worthy act. “Saving a life is giving life, and it earns merit (gain Boon)” #178 Perception that AEDs are designed only for trained people or professional use A significant number of participants expressed concerns regarding their knowledge and ability to assist patients experiencing out-of-hospital cardiac arrest. Many participants believed that those providing assistance should be trained, knowledgeable, and confident in performing CPR and using an AED. “We must help our fellow humans but within the bounds of basic knowledge” #13 Eight volunteers who had previously undergone training were willing to assist because of their basic lifesaving training backgrounds. “I want to help. Moreover, I have undergone training for it” #207 Thirty-eight volunteers believed they lacked sufficient knowledge and were concerned about performing CPR or using an AED incorrectly: “I do not know the correct way to use it” (#260) “I am unsure about the steps because I was trained a long time ago” (#136) Some volunteers believed that such interventions should be the responsibility of doctors, viewing AEDs as medical devices best handled by medical professionals: “I am not a doctor” (#236) “Medical devices should only be used by doctors” (#140) Five volunteers felt capable of performing CPR but preferred medical professionals use AEDs: “I will do basic CPR first; if the situation does not improve, it is better to let experts handle it” (#169) Fear to use AED Many volunteers expressed fear regarding their ability to provide assistance, particularly the fear of causing further harm or injury to the patient: “I don’t know how to use it and using it without knowing how could make the patient's condition worse” (#63) A smaller number of volunteers were concerned about the electricity or their own safety: “I am concerned about the electricity; I prefer CPR” (#127) “I think one should undergo training first, as there is considerable amount of electrical current involved. If we do not know how to use it, we might become patients ourselves” #72 When asked whether having a command center to provide instructions over the phone would help, several volunteers believed that having support from command center staff would increase confidence, ensure the application of correct procedures, and provide accountability. “I am happy to help because it is about saving lives. Moreover, with guidance from the command center, there should not be any mistakes or risks” #93 “The other party has demonstrated responsibility” # 236 Discussion This study provides comprehensive insights into the barriers to and facilitators of AED use in Khon Kaen. Despite the relatively low AED training rates (10.5%) and confidence levels (13.2%), approximately half of the participants (49.7%) expressed willingness to use AEDs during emergency. In South Korea, a low training rate correlates with low willingness [ 11 ]; in China, high willingness persists despite a low training rate [ 7 ]; and in the UK, the training rate is 19.4%, with 34.9% willing to use AEDs [ 12 ]. This illustrates the diverse relationships between training rates and willingness. The analysis of open-ended survey responses explains the high willingness of participants due to strong cultural and moral motivations. The participants frequently expressed humanitarian reasons, moral obligations, and religious motivations as driving forces behind their willingness to help. This religious–cultural motivation adds a new dimension to the existing literature on bystander intervention and suggests that Thai cultural and religious values could help lead to successful promotion of AED use, particularly when integrated with proper training and support systems. This study indicates that previous AED training played a role in the willingness to use AEDs. Analysis of narrative comments highlights why training makes a difference: it not only imparts technical knowledge but also instills a sense of obligation and authorization to assist, thereby enhancing the effectiveness of interventions. In terms of obligation to intervene, section 374 of the Thai Criminal Code reflects the societal expectation to assist in emergencies by mandating individuals who witness life-threatening situations to intervene, assuming no risk to themselves or others [ 13 ]. Unlike Good Samaritan laws that shield voluntary helpers from liability, this mandate promotes proactive assistance. However, it could also inadvertently restrict individual liberty and lead to hesitance or avoidance of intervention due to fear of legal repercussions. In contrast, the Emergency Medical Services Act B.E. 2551 (2008) encourages but does not require public use of AEDs by non-medical individuals, aiming to create a supportive environment for emergency interventions without making it compulsory [ 14 ]. Our findings reveal a significant public misconception: many believe that only trained professionals should use AEDs. This misunderstanding significantly undermines the effectiveness of the Emergency Medical Services Act and the broader objectives of public health and safety initiatives. Here, the finding that telephone assistance significantly increases willingness to use AEDs aligns with the results of previous research. For example, a previous study evaluating dispatcher-assisted public-access defibrillation programs demonstrated a significant increase in bystander-initiated AED usage following the implementation of such programs [ 15 ]. However, our content analysis of free-text responses provides novel insights into why this increase occurs: telephone assistance not only provides technical guidance but also provides authorization and shares the psychological burden of responsibility. This is particularly relevant, given the identified fear of litigation and causing harm. The strong influence of cultural and religious values on willingness to help, combined with the significant impact of telephone assistance, suggests a unique opportunity to improve AED use in Thailand. Despite only 10.5% of the participants having undergone AED training, this study found that willingness to help was driven by strong cultural and religious motivations for merit-making. However, the misconception that AEDs should only be used by medical professionals remains a significant barrier. Moreover, the contradiction between the Thai Criminal Code, which mandates intervention in emergencies, and the Emergency Medical Services Act, which encourages but does not require public use of AEDs, creates confusion and may hinder effective action. Our findings suggest that incorporating cultural values into public training programs, correcting misconceptions about the restriction of AED use to healthcare professionals, addressing specific fears through telephone support systems, and establishing clear legal protections for lay rescuers may be particularly effective in the Thai context. This study has some limitations. The study population had a relatively high proportion of young and educated individuals (47.6% aged 18–30 years; 46.8% with a bachelor’s degree). According to the Human Achievement Index (HAI), Khon Kaen ranks above the national average for education, which may partly explain the overrepresentation of highly educated participants in our sample. However, this characteristic may limit the generalizability of the findings to regions with lower educational attainment and may not fully reflect the broader population. Future research should aim for a more diverse sample by actively recruiting older adults, individuals with varied educational backgrounds, and members of underrepresented communities to enhance representativeness. Additionally, the self-reported nature of the data may be subject to social desirability bias, particularly regarding willingness to help others. While the free-text responses approach provided valuable insights, using written questionnaires as a method minimized interviewer influence, thereby reducing bias and allowing participants to express their perspectives more freely. However, unlike interviews or focus groups, this method lacked real-time probing, which limited opportunities to clarify ambiguous responses or explore participants’ thoughts in greater depth. To overcome this limitation, future studies could employ a combination of written questionnaires and follow-up interviews or focus groups to enhance the depth and richness of the qualitative findings. Conclusion The study revealed that Khon Kaen residents are motivated to assist during emergencies but face significant barriers to AED use, primarily due to a lack of training and misconceptions about who can operate AEDs. Addressing these barriers could enhance bystander intervention rates and improve outcomes for out-of-hospital cardiac arrest victims. Abbreviations EMS Emergency medical services AEDs Automated external defibrillators CPR Cardiopulmonary resuscitation Declarations The authors report there are no competing interests to declare. Ethics approval and consent to participate This study was reviewed and determined to be exempt from full ethical review by the Human Research Ethics Committee of Khon Kaen University. The study protocol (HE661172) was acknowledged in the committee meeting No. 16/2566, Agenda 3.3.01, on April 19, 2023. Informed consent was implied; participation was voluntary, and answering the questionnaire signified consent. The research adhered to relevant ethical guidelines and regulations. Consent for publication Not applicable. This study does not contain any individual person’s data in any form (including images or personal details) that requires consent for publication. Availability of data and materials The de-identified dataset supporting the findings of this study is available from the corresponding author upon reasonable request (email: [email protected] ) Competing interests The authors declare that they have no competing interests Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors Authors' contributions Supawadee Pudjapo: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing-original draft Marturod Buranasakda: Data curation, formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Visualization, Validation, Writing – review & editing Acknowledgments The authors would like to thank Dr. Ratrawee Pattanarattanamolee for his valuable insights and thoughtful critiques, which contributed to the refinement of this study. 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Effects of dispatcher-assisted public‐access defibrillation programs on the outcomes of out‐of‐hospital cardiac arrest: a before‐and‐after study. J Am Heart Assoc. 2024;13:e031662. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile3additionalquotes.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers agreed at journal 14 Oct, 2025 Reviewers invited by journal 09 Oct, 2025 Editor invited by journal 17 Sep, 2025 Editor assigned by journal 15 Sep, 2025 Submission checks completed at journal 15 Sep, 2025 First submitted to journal 10 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7580807","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":532698295,"identity":"ac67c159-8dd0-4152-be76-0e0ec716f18f","order_by":0,"name":"S Pudjapo","email":"","orcid":"","institution":"Khon Kaen University","correspondingAuthor":false,"prefix":"","firstName":"S","middleName":"","lastName":"Pudjapo","suffix":""},{"id":532698297,"identity":"fa8c8700-dd6a-4a62-a3c7-dcec2eca2376","order_by":1,"name":"M 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10:20:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":758641,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7580807/v1/867b9379-4bd8-43f2-8a30-06e5620814fc.pdf"},{"id":94096445,"identity":"65e47ae9-da56-4cb9-aa23-9394df3c4722","added_by":"auto","created_at":"2025-10-22 10:04:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17653,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile3additionalquotes.docx","url":"https://assets-eu.researchsquare.com/files/rs-7580807/v1/3a5f46eb4bed377f9cdd44f4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers to automated external defibrillator use among urban residents in Khon Kaen, Thailand: A cross-sectional survey","fulltext":[{"header":"Background","content":"\u003cp\u003eSudden cardiac arrest was once considered futile. However, over the past two decades, a robust prehospital system has considerably improved survival rates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Immediate assistance with chest compressions can increase the survival rate by 2\u0026ndash;3 times [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and when combined with an automated external defibrillator (AED), the survival rate can reach up to 70% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The effectiveness of bystander defibrillation is apparent, with the number needed to treat (NNT) being 6 for 30-day survival, compared to 112 for adrenaline [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Khon Kaen city, Thailand, with a population of nearly 500,000, approximately 200 cases of out-of-hospital cardiac arrest are recorded annually. Despite having over 60 serviceable AEDs in the city, less than 10 cases per year over the past 5 years have involved bystander defibrillation prior to the arrival of emergency medical services (EMS). Globally, the use of AEDs in real-world cardiac arrest situations is similarly low. Common issues include a lack of public awareness about the existence and locations of AEDs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], insufficient training [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and the public's reluctance to use AEDs due to fear of harm or legal repercussions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Cultural factors, such as reluctance to touch strangers and intervene in emergency situations, also play an important role [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Thailand, initiatives to teach basic life support in schools and universities and to train community volunteers are in place. However, AED use in cardiac arrest cases in Khon Kaen remains limited. To date, research examining the impediments to AED deployment in Khon Kaen or similar mid-sized urban regions in Thailand remains limited. Although previous Thai studies have primarily focused on general CPR awareness or EMS efficiency, they have not addressed the specific challenges associated with AED usage in localized settings. Therefore, in order to bridge this knowledge gap, we conducted a survey to understand why this life-saving technology is not being effectively utilized in the city.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003eThis cross-sectional survey was conducted to explore possible barriers to AED use among Khon Kaen residents. Data were collected using open- and closed-ended questionnaires between July 1 and August 31, 2023. The manuscript was prepared in accordance with the \u003cb\u003eConsensus-based Checklist for Reporting of Survey Studies (CROSS)\u003c/b\u003e (Supplementary File 1).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe study targeted volunteers aged\u0026thinsp;\u0026gt;\u0026thinsp;18 years living in Khon Kaen city. Medical personnel were excluded to focus on the general public's perspective.\u003c/p\u003e\n\u003ch3\u003eSampling of participants\u003c/h3\u003e\n\u003cp\u003eThe sample size for the study was calculated using a population proportion formula based on the 2020 population of Khon Kaen city. Using a 95% confidence level, a 5% margin of error, and an expected proportion of 50% (a conservative estimate in the absence of prior data), the required sample size was determined to be 385. Data of 387 participants, including 178 web-based and 209 paper-based questionnaire respondents, were successfully collected. After data cleaning, 370 responses were included in the final analysis. For narrative comments, sample size considerations are often guided by the principle of data saturation, which in grounded theory studies is typically reached with 20\u0026ndash;30 participants [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. For written responses or open-ended survey items, however, no formal sample size guidelines exist. In this study, 205 narrative responses were obtained, which allowed for a robust thematic analysis of perceived barriers to AED use.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary objective was to identify barriers and challenges to AED use in Khon Kaen city. The primary outcome was the willingness to use an AED during cardiac arrest. Key predictors included previous CPR and AED training, self-reported confidence in using an AED, knowledge and awareness of AEDs, and willingness to perform CPR, including willingness to use an AED under telephone assistance. Demographic characteristics (age, sex, education, occupation, and religion) were collected as covariates. In addition, open-ended responses explored perceived motivations and barriers to AED use, which were analyzed qualitatively to identify themes.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003e The questionnaire was developed based on previous studies, the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, and the 2021 European Resuscitation Council Guidelines as references (Supplementary File 2). Before implementation, it underwent pilot testing with six participants to assess clarity, comprehension, and item flow items. Minor wording and usability adjustments were made based on their feedback. The finalized questionnaire was distributed in both online (via Google Forms) and paper formats through social media (Facebook: Khon Kaen and KKU group) and in public locations such as markets, parks, shopping malls, food courts, and university cafeterias.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003eClosed-ended survey response analysis\u003c/h2\u003e\u003cp\u003eAll responses were entered in Excel. Nominal and ordinal data are presented as frequency and percentage, respectively. Chi-squared test was used to identify significant differences between categorical variables and explore relationships affecting AED use. Scale data were tested for normality; they are presented as mean and standard deviation. Statistical analyses were performed using SPSS software (IBM SPSS for Windows, Version 26).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eOpen-ended survey response analysis\u003c/h3\u003e\n\u003cp\u003eNarrative comments from both paper-based and online questionnaires were transcribed into Microsoft Word. Two researchers independently reviewed transcripts to ensure accuracy. Content analysis was used to maintain the natural meaning of the responses. The analysis followed an inductive approach, involving systematic condensation of data into initial codes, which were then divided into broader categories. These categories were further refined to identify overarching themes. Disagreements in coding were resolved through discussions between the researchers until a consensus was reached. This systematic process ensured that the natural state of the data was preserved and minimized researcher bias. Consensus among researchers confirmed that they had identified all significant patterns in the data set.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eIntegration of findings\u003c/h2\u003e\u003cp\u003eThe results of both closed- and open-ended analyses were integrated to provide a comprehensive understanding of the barriers and challenges associated with AED use in Khon Kaen.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003ch3\u003eClosed-ended survey results\u003c/h3\u003e\n\u003cp\u003eA total of 387 volunteers participated in the survey, of whom 209 responded to the paper-based survey and 178 responded to the online survey. Seventeen respondents did not complete the survey or meet the study criteria, resulting in 370 volunteers being included in the study. The majority of respondents were female individuals (65.9%). Overall, nearly one-third (32.9%) of the participants were university students. While 70% of the volunteers had heard about CPR, only 26.2% had received CPR training, and 10.5% had received AED training (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e: Characteristics of the study population (N=370)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eCharacteristics \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eNumber (%) N=370\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e244(65.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;18\u0026ndash;30\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;31\u0026ndash;50\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cu\u003e\u0026gt;\u003c/u\u003e 51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e176(47.6)\u003c/p\u003e\n \u003cp\u003e98(26.5)\u003c/p\u003e\n \u003cp\u003e96(25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;University student\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Government section\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e122(32.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 56(15.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 192(52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eReligious Affiliation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Buddhism\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e351(94.9)\u003c/p\u003e\n \u003cp\u003e19(5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eEducation Level\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;High school and under\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bachelor\u0026apos;s degree\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e138(37.3)\u003c/p\u003e\n \u003cp\u003e173(46.8)\u003c/p\u003e\n \u003cp\u003e59(15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eHeard about CPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e262(70.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eUnderwent Previous CPR Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e97(26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eUnderwent AED Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e39(10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eConfidence to use AED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e49(13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCPR, cardiopulmonary resuscitation; AED, automated external defibrillator\u003c/p\u003e\n\u003cp\u003eHere, 54% of volunteers were willing to perform CPR on patients with out-of-hospital cardiac arrest, whereas 50% were willing to perform CPR and use an AED. If medical personnel provided assistance over the phone, the willingness to use AED increased to 71% (Table 2). On analyzing factors influencing the willingness to use an AEDs, volunteers familiar with or aware of AEDs were more willing to use them in patients experiencing out-of-hospital cardiac arrest than those who were not familiar (53.9% vs. 18.0%, p=0.008). Additionally, volunteers trained in AED use (46.2%) or who knew how to use the device (61.3%) were significantly more willing to use it (p\u0026lt;0.001 for both) (Table 3).\u003c/p\u003e\n\u003cp\u003eTable 2. Willingness to perform CPR and use an AED among respondents\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"665\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 485px;\"\u003e\n \u003cp\u003eWillingness\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNumber (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"666\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 495px;\"\u003e\n \u003cp\u003eWillingness to perform CPR\u003c/p\u003e\n \u003cp\u003eWillingness to perform CPR and use AED\u003c/p\u003e\n \u003cp\u003eWillingness to perform CPR and use AED under telephone assistance\u003c/p\u003e\n \u003cp\u003eWillingness to attend first aid and AED use training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e201(54.3)\u003c/p\u003e\n \u003cp\u003e184(49.7)\u003c/p\u003e\n \u003cp\u003e263(71.1)\u003c/p\u003e\n \u003cp\u003e265(71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCPR, cardiopulmonary resuscitation; AED, automated external defibrillator\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e. Willingness to use an AED among respondents (N=370)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eNumber N=370\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eWilling to use AED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eNot willing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eUnsure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eHave heard about AED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e206(55.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e34(18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e111(53.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e58(28.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eHave seen an AED\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e113(30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e19(16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;61(54.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e33(29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eKnow what an AED is used for\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;87(23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21(24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;41(47.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e25(28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eHave undergone AED training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;39(10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e18(46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;13(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;8(20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eKnow how to use an AED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e31(8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e19(61.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; 7(22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5(16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAED, automated external defibrillator\u003c/p\u003e\n\u003cp\u003eDrawing from barriers to AED use previously identified in the literature, we categorized these barriers into three levels: strong, moderate, and mild. Most barriers were perceived as mild to moderate rather than strong. Lack of knowledge was identified as a notable concern, with 24.7% of respondents rating it as a strong barrier and 34.2% as a moderate barrier. Fear of litigation was reported by 29.5% of respondents as a strong barrier and by 34.7% as a moderate barrier. Fear of physical contact with strangers was predominantly moderate (41.9%) to mild (42.9%). Gender-related concerns were present but less prominent. Exposure of the chest area to attach an AED was mostly a mild concern, with 63.9% rating it as such for women and 51.5% for men. Technical concerns, such as fear of electric shock, were predominantly mild (50.3%) to moderate (36.4%) (Table 4).\u003c/p\u003e\n\u003cp\u003eTable 4. Identified barriers to AED use among respondents\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"684\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eBarriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eRespondents (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eStrong (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eModerate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eMild (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eLack of knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e73(24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e101(34.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e121(41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eFear of physical contact with a stranger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e305\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e46(15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e128(41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e131(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eFear of disease contraction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e50(16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e109(35.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e149(48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eFear of the opposite sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e307\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e36(11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;95(30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e176(57.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eFear of exposing the chest area while attaching the AED in women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e37(12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e74(24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e197(63.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eFear of exposing the chest area while attaching the AED in the opposite sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e307\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e43(14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e106(34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e158(51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eFear of causing harm to a victim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e73(23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e121(39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e114(37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eFear of electric shock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e41(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e112(36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e155(50.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eFear of litigation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e91(29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e107(34.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e110(35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAED, automated external defibrillator\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the reasons why volunteers wanted or did not want to participate in CPR and AED training, those who wanted to participate did so to gain additional knowledge, prepare for emergencies, and help others or family members. Some volunteers wanted to attend training sessions to refresh their knowledge and ensure they follow correct procedures.\u003c/p\u003e\n\u003cp\u003eIn contrast, those who did not want to participate in CPR and AED training cited various reasons, including inconvenience and lack of time. Two volunteers mentioned that they could learn from the internet without attending classroom training. Two others cited age, and one volunteer cited poor health as reasons for not participating. Additionally, one volunteer did not want to attend training because of fear of blood.\u003c/p\u003e\n\u003ch3\u003eOpen-ended survey results\u003c/h3\u003e\n\u003cp\u003eThe analysis of open-ended survey responses from 205 participants highlighted three key themes surrounding barriers to AED use in Khon Kaen. \u003cstrong\u003eFirst, motivation to help\u003c/strong\u003e emerged as a strong driver, with participants expressing humanitarian values, a sense of moral duty, and altruism as reasons for assisting in emergencies. \u003cstrong\u003eSecond, the perception that AEDs are designed only for trained persons or professional use\u003c/strong\u003e revealed a lack of confidence and knowledge, along with the belief that only medical professionals should handle AEDs. \u003cstrong\u003eThird, fear of using an AED\u003c/strong\u003e underscored concerns about causing harm, personal safety, and potential legal repercussions. Together, these themes illustrate both the willingness and hesitations of bystanders, offering insights into strategies to improve AED use in emergencies (Table 5; additional illustrative quotes are available in Supplementary File 3).\u003c/p\u003e\u003cp\u003eTable 5. Themes, categories, and codes identified from the analysis of open-ended survey responses on barriers to AED use in Khon Kaen City.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"113%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCode\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eMotivation to help\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDesire for the patient\u0026apos;s survival\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eHumanitarian values\u0026nbsp;and compassion (feeling sorry for the patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eAltruism (want to/desire to help)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eA sense of moral obligation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 252px;\"\u003e\n \u003cp\u003eMoral imperative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eCultural norms and Buddhist teachings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eTo gain merit (Boon)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003ePerception that AEDs are designed only for trained persons or professional use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003eNeed for AED training\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eLack of knowledge and confidence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003ePrevious training provides confidence and a sense of authority in using an AED\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eBelief in the need for certification or formal training\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eReserved for doctors or medical staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003eOnly doctors or medical staffs should do it\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eFear to use AED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eFear of further harm to patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e- Fear of causing more harm\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eFear of harm to self\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e- Fear for one\u0026rsquo;s own safety\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eFear of litigation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 252px;\"\u003e\n \u003cp\u003e- Fear of legal responsibility for the patient\u0026rsquo;s outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAED, automated external defibrillator\u003c/p\u003e\n\u003ch3\u003eMotivation to help\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eWhen participants were asked about their willingness to provide CPR\u0026nbsp;and use AEDs\u0026nbsp;for patients with out-of-hospital cardiac arrest, many expressed a strong willingness to help.\u0026nbsp;The primary motivations cited were a desire for patient survival and a profound sense of moral obligation.\u0026nbsp;Many participants viewed their willingness to help as driven by humanitarian reasons.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I feel sorry for fellow human beings\u0026rdquo;\u0026nbsp;#107\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Our sense of humanity doesn\u0026apos;t allow us to stand by and let a fellow human die right in front of us\u0026nbsp;😊😊\u0026rdquo;\u0026nbsp;#65\u003c/p\u003e\n\u003cp\u003eSixty participants expressed their willingness to help out of altruism, and they were willing to intervene because they get to help patients.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I want to \u0026nbsp;help\u0026rdquo;\u0026nbsp;#183\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;You can be a hero too!!!!\u0026rdquo;\u0026nbsp;#167\u003c/p\u003e\n\u003cp\u003eTen participants viewed providing CPR as a basic duty, moral imperative, or necessary action:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Saving lives is the right thing to do\u0026rdquo;\u0026nbsp;#34\u003c/p\u003e\n\u003cp\u003eFour participants believed that performing CPR and using AED means helping others and that it is merit-worthy act.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Saving a life is giving life, and it earns merit\u0026nbsp;(gain Boon)\u0026rdquo;\u0026nbsp;#178\u003c/p\u003e\n\u003ch3\u003ePerception that AEDs are designed only for trained people or professional use\u003c/h3\u003e\n\u003cp\u003eA significant number of participants expressed concerns regarding their knowledge and ability to assist patients experiencing out-of-hospital cardiac arrest.\u0026nbsp;Many participants believed that those providing assistance should be trained, knowledgeable, and confident in performing CPR\u0026nbsp;and using an AED.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We must help our fellow humans but within the bounds of basic knowledge\u0026rdquo;\u0026nbsp;#13\u003c/p\u003e\n\u003cp\u003eEight volunteers who had previously undergone training were willing to assist because of their basic lifesaving training backgrounds.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I want to help.\u0026nbsp;Moreover, I have undergone training for it\u0026rdquo;\u0026nbsp;#207\u003c/p\u003e\n\u003cp\u003eThirty-eight volunteers believed they lacked sufficient knowledge and were concerned about performing CPR or using an AED incorrectly:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I do not know the correct way to use it\u0026rdquo;\u0026nbsp;(#260)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026ldquo;I am unsure about the steps because I was trained a long time ago\u0026rdquo;\u0026nbsp;(#136)\u003c/p\u003e\n\u003cp\u003eSome volunteers believed that such interventions should be the responsibility of doctors, viewing AEDs\u0026nbsp;as medical devices best handled by medical professionals:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I am not a doctor\u0026rdquo;\u0026nbsp;(#236)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Medical devices should only be used by doctors\u0026rdquo; (#140)\u003c/p\u003e\n\u003cp\u003eFive volunteers felt capable of performing CPR\u0026nbsp;but preferred medical professionals use AEDs:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I will do basic CPR\u0026nbsp;first; if the situation does not improve, it is better to let experts handle it\u0026rdquo; (#169)\u003c/p\u003e\n\u003ch3\u003eFear to use AED\u003c/h3\u003e\n\u003cp\u003eMany volunteers expressed fear regarding their ability to provide assistance, particularly the fear of causing further harm or injury to the patient:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I don\u0026rsquo;t know how to use it and using it without knowing how could make the patient\u0026apos;s condition worse\u0026rdquo; (#63)\u003c/p\u003e\n\u003cp\u003eA smaller number of volunteers were concerned about the electricity or their own safety:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I am concerned about the electricity; I prefer CPR\u0026rdquo; (#127)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think one should undergo training first, as there is considerable amount of electrical current involved. If we do not know how to use it, we might become patients ourselves\u0026rdquo; #72\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen asked whether having a command center to provide instructions over the phone would help, several volunteers believed that having support from command center staff would increase confidence, ensure the application of correct procedures, and provide accountability.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I am happy to help because it is about saving lives. Moreover, with guidance from the command center, there should not be any mistakes or risks\u0026rdquo; #93\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The other party has demonstrated responsibility\u0026rdquo; # 236\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides comprehensive insights into the barriers to and facilitators of AED use in Khon Kaen. Despite the relatively low AED training rates (10.5%) and confidence levels (13.2%), approximately half of the participants (49.7%) expressed willingness to use AEDs during emergency. In South Korea, a low training rate correlates with low willingness [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]; in China, high willingness persists despite a low training rate [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]; and in the UK, the training rate is 19.4%, with 34.9% willing to use AEDs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This illustrates the diverse relationships between training rates and willingness.\u003c/p\u003e\u003cp\u003eThe analysis of open-ended survey responses explains the high willingness of participants due to strong cultural and moral motivations. The participants frequently expressed humanitarian reasons, moral obligations, and religious motivations as driving forces behind their willingness to help. This religious\u0026ndash;cultural motivation adds a new dimension to the existing literature on bystander intervention and suggests that Thai cultural and religious values could help lead to successful promotion of AED use, particularly when integrated with proper training and support systems.\u003c/p\u003e\u003cp\u003eThis study indicates that previous AED training played a role in the willingness to use AEDs. Analysis of narrative comments highlights why training makes a difference: it not only imparts technical knowledge but also instills a sense of obligation and authorization to assist, thereby enhancing the effectiveness of interventions. In terms of obligation to intervene, section 374 of the Thai Criminal Code reflects the societal expectation to assist in emergencies by mandating individuals who witness life-threatening situations to intervene, assuming no risk to themselves or others [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Unlike Good Samaritan laws that shield voluntary helpers from liability, this mandate promotes proactive assistance. However, it could also inadvertently restrict individual liberty and lead to hesitance or avoidance of intervention due to fear of legal repercussions.\u003c/p\u003e\u003cp\u003eIn contrast, the Emergency Medical Services Act B.E. 2551 (2008) encourages but does not require public use of AEDs by non-medical individuals, aiming to create a supportive environment for emergency interventions without making it compulsory [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our findings reveal a significant public misconception: many believe that only trained professionals should use AEDs. This misunderstanding significantly undermines the effectiveness of the Emergency Medical Services Act and the broader objectives of public health and safety initiatives.\u003c/p\u003e\u003cp\u003eHere, the finding that telephone assistance significantly increases willingness to use AEDs aligns with the results of previous research. For example, a previous study evaluating dispatcher-assisted public-access defibrillation programs demonstrated a significant increase in bystander-initiated AED usage following the implementation of such programs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, our content analysis of free-text responses provides novel insights into why this increase occurs: telephone assistance not only provides technical guidance but also provides authorization and shares the psychological burden of responsibility. This is particularly relevant, given the identified fear of litigation and causing harm.\u003c/p\u003e\u003cp\u003eThe strong influence of cultural and religious values on willingness to help, combined with the significant impact of telephone assistance, suggests a unique opportunity to improve AED use in Thailand. Despite only 10.5% of the participants having undergone AED training, this study found that willingness to help was driven by strong cultural and religious motivations for merit-making. However, the misconception that AEDs should only be used by medical professionals remains a significant barrier. Moreover, the contradiction between the Thai Criminal Code, which mandates intervention in emergencies, and the Emergency Medical Services Act, which encourages but does not require public use of AEDs, creates confusion and may hinder effective action. Our findings suggest that incorporating cultural values into public training programs, correcting misconceptions about the restriction of AED use to healthcare professionals, addressing specific fears through telephone support systems, and establishing clear legal protections for lay rescuers may be particularly effective in the Thai context.\u003c/p\u003e\u003cp\u003eThis study has some limitations. The study population had a relatively high proportion of young and educated individuals (47.6% aged 18\u0026ndash;30 years; 46.8% with a bachelor\u0026rsquo;s degree). According to the Human Achievement Index (HAI), Khon Kaen ranks above the national average for education, which may partly explain the overrepresentation of highly educated participants in our sample. However, this characteristic may limit the generalizability of the findings to regions with lower educational attainment and may not fully reflect the broader population. Future research should aim for a more diverse sample by actively recruiting older adults, individuals with varied educational backgrounds, and members of underrepresented communities to enhance representativeness. Additionally, the self-reported nature of the data may be subject to social desirability bias, particularly regarding willingness to help others. While the free-text responses approach provided valuable insights, using written questionnaires as a method minimized interviewer influence, thereby reducing bias and allowing participants to express their perspectives more freely. However, unlike interviews or focus groups, this method lacked real-time probing, which limited opportunities to clarify ambiguous responses or explore participants\u0026rsquo; thoughts in greater depth. To overcome this limitation, future studies could employ a combination of written questionnaires and follow-up interviews or focus groups to enhance the depth and richness of the qualitative findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study revealed that Khon Kaen residents are motivated to assist during emergencies but face significant barriers to AED use, primarily due to a lack of training and misconceptions about who can operate AEDs. Addressing these barriers could enhance bystander intervention rates and improve outcomes for out-of-hospital cardiac arrest victims.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEMS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEmergency medical services\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAEDs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAutomated external defibrillators\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCPR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCardiopulmonary resuscitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors report there are no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and determined to be exempt from full ethical review by the Human Research Ethics Committee of Khon Kaen University. The study protocol (HE661172) was acknowledged in the committee meeting No. 16/2566, Agenda 3.3.01, on April 19, 2023. Informed consent was implied; participation was voluntary, and answering the questionnaire signified consent. The research adhered to relevant ethical guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study does not contain any individual person\u0026rsquo;s data in any form (including images or personal details) that requires consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe de-identified dataset supporting the findings of this study is available from the corresponding author upon reasonable request (email: [email protected])\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupawadee Pudjapo: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing-original draft\u003c/p\u003e\n\u003cp\u003eMarturod Buranasakda: Data curation, formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Visualization, Validation, Writing \u0026ndash; review \u0026amp; editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Dr. Ratrawee Pattanarattanamolee for his valuable insights and thoughtful critiques, which contributed to the refinement of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePollack RA, Brown SP, Rea T, Aufderheide T, Barbic D, Buick JE, et al. Impact of bystander automated external defibrillator use on survival and functional outcomes in shockable observed public cardiac arrests. Circulation. 2018;137:2104\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHasselqvist-Ax I, Riva G, Herlitz J, Rosenqvist M, Hollenberg J, Nordberg P, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2015;372:2307\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eValenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000;343:1206\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKitamura T, Kiyohara K, Sakai T, Matsuyama T, Hatakeyama T, Shimamoto T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med. 2016;375:1649\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;379:711\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang CT, Chen CH, Huang CH, Fan CY, Chen JW, Ma MHM, et al. Public awareness of automated external defibrillator locations. JAMA Netw Open. 2024;7:e2438319.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang YM, Lin LT, Jiang JH, Jiang Y, Jin XQ. Public knowledge and attitudes toward automated external defibrillators use among first aid eLearning course participants: a survey. J Cardiothorac Surg. 2022;17:119.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDaud A, Nawi AM, Aizuddin AN, Yahya MF. Factors and barriers on cardiopulmonary resuscitation and automated external defibrillator willingness to use among the community: a 2016\u0026ndash;2021 systematic review and data synthesis. Glob Heart. 2023;18:46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreswell JW. Qualitative inquiry and research design: choosing among five traditions, xv. Thousand Oaks, CA: Sage Publications, Inc; 1998. p. 403.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMason M. Sample size and saturation in PhD studies using qualitative interviews. Forum Qual Sozialforsch, 11; 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee JH, Lee DE, Ryoo HW, Moon S, Cho JW, Kim YJ, et al. Public awareness and willingness to use automated external defibrillators in a metropolitan city. Clin Exp Emerg Med. 2021;8:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHawkes CA, Brown TP, Booth S, Fothergill RT, Siriwardena N, Zakaria S, et al. Attitudes to cardiopulmonary resuscitation and defibrillator use: a survey of UK adults in 2017. J Am Heart Assoc. 2019;8:e008267.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThailand P, Code BE. 2499, Section 374, as amended B.E; 1956. p. 2558 (2015). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://library.siam-legal.com/thai-law/criminal-code-misdemeanors-sections-367-374/\u003c/span\u003e\u003cspan address=\"https://library.siam-legal.com/thai-law/criminal-code-misdemeanors-sections-367-374/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed April 7, 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEmergency Medical Committee. Announcement of emergency medical committee on designation of automated external defibrillator use as first aid B.E. 2558. R Thai Gov Gaz. 2015;132(Special 124d). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.niems.go.th/1/upload/migrate/file/256004211126059708_buUaNTZDwOtjh84G.pdf\u003c/span\u003e\u003cspan address=\"https://www.niems.go.th/1/upload/migrate/file/256004211126059708_buUaNTZDwOtjh84G.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed April 22, 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang CH, Chien CY, Ng CJ, Fang SY, Wang MF, Lin CC, et al. Effects of dispatcher-assisted public‐access defibrillation programs on the outcomes of out‐of‐hospital cardiac arrest: a before‐and‐after study. J Am Heart Assoc. 2024;13:e031662.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"automatic external defibrillator, out-of-hospital cardiac arrest, cardiac arrest, cardiopulmonary resuscitation, emergency medical services","lastPublishedDoi":"10.21203/rs.3.rs-7580807/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7580807/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAutomated external defibrillators (AEDs) can improve survival rates in individuals experiencing cardiac arrest; however, their widespread use in Khon Kaen, Thailand, is limited. We aimed to understand why this life-saving technology is not being effectively utilized in the city.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a cross-sectional survey among residents of Khon Kaen using a structured questionnaire with both closed- and open-ended items. Closed-ended survey responses were analyzed descriptively, while open-ended responses underwent content analysis to identify major themes. Findings from both components were then integrated to provide a comprehensive understanding of barriers to AED use.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 370 respondents, approximately half were willing to use an AED during cardiac arrest. However, with telephone-assisted cardiopulmonary resuscitation (CPR), the willingness to perform CPR and use an AED increased to 71%. A major barrier was the small number of trained individuals in the city (10.5%). The second significant barrier was the misunderstanding that only trained individuals are permitted to use AEDs. Respondents perceived training in CPR and AED use as essential for providing the necessary knowledge and courage, as well as authorizing and obligating them to use AEDs in real-life situations.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis study revealed that the willingness of Khon Kaen residents to use AEDs is hindered by a lack of training and misconceptions that only trained individuals can use them. Public education and training programs, along with promotion of telephone-assisted CPR, could enhance bystander response and improve AED use.\u003c/p\u003e","manuscriptTitle":"Barriers to automated external defibrillator use among urban residents in Khon Kaen, Thailand: A cross-sectional survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-22 10:04:01","doi":"10.21203/rs.3.rs-7580807/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-17T14:14:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200418829954426439651265419847640968615","date":"2025-10-16T09:48:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335317950535666376536287289173291875118","date":"2025-10-16T07:57:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40533592791033976187495893203966179281","date":"2025-10-14T06:47:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-09T06:36:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-17T05:58:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-15T08:51:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-15T08:51:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2025-09-10T08:51:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55bfacdc-fedf-4d46-be8e-b868b1a29366","owner":[],"postedDate":"October 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-22T10:04:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-22 10:04:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7580807","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7580807","identity":"rs-7580807","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}