Out-of-Hospital Cardiac Arrest (OHCA) is a major public health challenge. The true burden of OHCA remains uncertain due to underreporting and the regional differences in data collection (1). Global data compiled by the International Liaison Committee on Resuscitation from 15 registries across North America, Europe, Asia, and Oceania estimated the incidence of EMS-treated OHCA at 30.0–100.2 per 100,000 population between 2015 and 2017, with survival to hospital discharge or 30-day survival ranging from 4.6 to 16.4%, underscoring substantial international disparities in outcomes (2). Official data sources and comprehensive population-based studies remain limited in the Middle East. Available evidence is largely derived from individual center-based studies, which report high mortality rates across several Gulf Cooperation Council countries (3). Overall, survival rates in the Middle East and Asia appear lower than global averages, with most regional studies reporting survival rates below 10% (4, 5). The PAROS study, which included data from Dubai, reported a survival rate of 3% in the United Arab Emirates (UAE) (6).

Bystander response plays a crucial role in the “Chain of Survival” framework, which emphasizes early recognition of cardiac arrest, Emergency Medical Services (EMS) activation, bystander cardiopulmonary resuscitation (CPR), and early defibrillation (7). The EuReCa TWO study across 28 European countries reported a 9.1% survival rate when CPR was initiated by bystanders, compared to 4.5% when started by EMS (8). CPR can increase survival two- to threefold (9, 10), while public automated external defibrillator (AED) use may raise survival chances by up to 75% (11). Despite this, bystander CPR rates range widely from 13% in Serbia to 82% in Norway (8), and AED use varies from 9.3% in Denmark to 59.3% in the Netherlands (12, 13). Various global initiatives have been introduced to improve both CPR and AED use (14, 15).

Data on OHCA outcomes in GCC countries is limited, with lower survival rates, decreased bystander response rates, and lower rates of AED use (5, 16). The PAROS study indicated a bystander response rate of 10.5% in the UAE, the lowest among the seven countries included from Asia and a bystander AED use rate of 0.8% (6). According to the Theory of Planned Behavior, an individual’s intention to act is influenced by attitudes, perceived social norms, and perceived control (17). While various studies from other regions have examined public attitudes and willingness to intervene in OHCA, there is a literature gap in the Middle East regarding attitudes, sociocultural and demographic factors influencing bystander response. The objective of this study was to identify predictors of willingness to perform CPR and use an AED, and to describe barriers and facilitators to bystander CPR and AED use in the UAE.

The study included 1,020 participants (mean age 28 ± 11 years), mostly young adults aged 18–35 (76%), with 60% women and 71% being Emiratis. Nearly half of the participants (49%) lived in Al-Ain, and 22% were healthcare providers. Only 51% knew the correct emergency contact number (Table 1).

This study identified the key predictors, barriers, and facilitators to bystander response to an OHCA in the UAE. Lower training rates were observed among females and South Asians, while AED training was also lower among residents of the Northern Emirates and those with lower education. Training was associated with higher confidence and more positive attitudes. Prior training emerged as the strongest predictor of willingness, with repeated training further increasing willingness. Additional predictors included being a healthcare provider, confidence in recognizing cardiac arrest, and belief in the effectiveness of bystander intervention (positive attitude). Bivariate analysis highlighted that more recent and repeated training was linked to higher confidence and greater willingness, demonstrating clear dose–response patterns. Attitudinal and experiential factors, including positive attitudes, the ability to recognize cardiac arrest, and witnessing a cardiac arrest, were additionally associated with higher willingness. Likelihood of performing CPR varied by the sex of the individual in cardiac arrest, with participants more likely to respond to same-sex individuals. Key barriers and facilitators included lack of skill and confidence, fear of causing harm, and legal concerns, and among trained participants who were unwilling to intervene, about half reported low confidence. These findings align with the Theory of Planned Behavior (17), highlighting strong links between willingness and confidence (control beliefs), perceived CPR effectiveness (behavioral beliefs), and prior training (which reinforces both). Social norms such as expectations related to sex and cultural attitudes toward helping strangers reflect the role of normative beliefs. Addressing all three belief domains is essential when designing interventions to promote bystander CPR and AED use.

In our study, 60.6% of participants were willing to perform CPR, and 46.8% were willing to use an AED. Studies have reported varying CPR willingness rates, with higher rates in studies from Taiwan (86.7%) and South Korea (67.5%), compared to lower rates in the UK (57.6%) and Austria (33%) (21–24). Similarly, AED willingness ranges from 43% in a South Korean study to 50% in an Austrian study (24, 25). In our study population, 52% had received CPR training, and 34% had AED training. The CPR training rate in our study was lower than the rates reported from Europe (59%) and North America (65%) but higher than previous studies from the Middle East (19%) (26). AED training rates from our sample matched a recent 2024 survey in Singapore (36%) but were notably higher than the 20% reported in the UK in 2017 (23, 27). However, in a recent study from Qatar, which shares a similar context to UAE, actual bystander CPR was provided in only 34% of out-of-hospital cardiac arrests, underscoring challenges in translating willingness into real-world action (28).

Our findings on training disparities align with previous studies, which have consistently reported lower CPR and AED training rates among certain demographic groups, including South Asians (29), individuals with lower education levels (30), and older adults (30). Females had lower CPR training rates, and although bivariate analysis showed reduced willingness to perform CPR, this was not significant in the multivariable model. Notably, lower willingness among females has been reported in the literature, supporting the relevance of gender as a factor in bystander response (21, 24). Regional variations in AED training rates, identified in our study, warrant further exploration to understand underlying factors. Previous training is a key predictor of willingness to perform CPR, showing a dose-dependent relationship between the number of training sessions and the odds of intervening, including AED use. This aligns with existing literature, which indicates that repeated training enhances willingness (22). Bivariate analysis further demonstrated that willingness decreases as the time since the last training increases, advocating for frequent refresher CPR training sessions. Prior studies have also highlighted skill decay over time, and the need for frequent CPR training sessions has been recommended (31).

Sex influenced CPR willingness based on the affected individual’s characteristics: women were more likely to help women and children, while men preferred assisting male individuals and family members. For AED use, sex differences were not significant when the individual in arrest was male, but men were less likely to use an AED on females. Supporting this, 23% cited same-sex individuals as a facilitator for AED use and 33% for CPR. These findings align with prior research showing women are less likely to receive CPR due to fears of inappropriate touch or accusations of sexual assault (30, 32).

The most reported barriers to CPR and AED use were lack of skill, confidence, uncertainty, fear of injury, and legal consequences, consistent with other studies (33). The most frequently cited barrier among trained individuals who expressed willingness to perform CPR was the fear of legal consequences. This underscores the critical need for increased public awareness regarding the Good Samaritan Law, which was enacted in the UAE in November 2020 (34). Notably, 50% of respondents identified legal protection as a key motivator for initiating CPR, emphasizing the law’s potential role in encouraging bystander intervention. The perception of legal concerns as a barrier varies across studies, potentially due to differing legislative frameworks and levels of public awareness (21, 33). Furthermore, among participants who were unwilling to perform CPR despite training, 55% cited a lack of confidence in their CPR skills, and 52% lacked confidence in using an AED. This highlights the importance of training programs that enhance both technical skills and psychological readiness.

Dispatcher-assisted CPR (DA-CPR) was identified as a key facilitator in our study, consistent with findings from the UK, where 82% of participants reported confidence if an emergency responder guides them (35). Around 35% of participants identified compression-only CPR (CO-CPR) as a facilitator. In another study, 61% preferred CO-CPR on unknown individuals, which means significant bystander CPR rates may be increased by promoting CO- CPR (33, 36).

Based on our findings, several targeted interventions are needed to improve bystander response to OHCA. Efforts to improve training rates could emphasize female inclusivity and outreach to underrepresented ethnic groups, especially South Asians. Variations across emirates should be further explored using more diverse samples to improve accessibility. Frequent, repeated training integrated into school curricula, linked to driver’s licenses, and supported by CPR self-training kits can increase training rates and bystander response, as seen in Denmark, where such measures doubled bystander CPR (37). Promoting DA-CPR and CO-CPR can further boost intervention. Cultural and religious concerns, particularly CPR on opposite-sex, culd be addressed through engagement with the community and religious leaders and legal concerns could be addressed by raising awareness about Good Samaritan laws. According to the willingness-centered bystander model, an individual’s decision to help is shaped by personal beliefs, social norms, and confidence in predicting the outcome of their actions (38), as demonstrated in our study, where a positive attitude was strongly associated with the willingness to perform CPR. These findings suggest that promoting positive beliefs about the potential life-saving impact of bystander CPR and AED use may support greater willingness to intervene.

Despite the Good Samaritan Law and existing CPR training programs, significant barriers to bystander intervention remain in the UAE. Our findings suggest that inclusive and culturally sensitive training, along with measures addressing behavioral barriers related to legal concerns and social norms, may help support bystander response in out-of-hospital cardiac arrest (OHCA) situations. Supportive approaches, such as dispatcher-assisted CPR and compression-only CPR, were also identified as potential facilitators. Representative national estimates of training and actual bystander CPR and AED use are needed. Furthermore qualitative research is needed to gain a deeper understanding of the social, cultural, and legal barriers affecting both trained and untrained bystanders.