Community Awareness and Engagement in Bleeding Control: A Cross-Sectional Study

Introduction

Road traffic accidents (RTA) are among the greatest public health challenges and burdens in many countries, Saudi Arabia included [1-5]. Globally, more than 1.2 million people die as a result of RTA, while 50 million are injured [6]. Road deaths in the Kingdom of Saudi Arabia (KSA) account for 4.7% of all deaths, with the number over the past decade increasing from 17.4 to 24 per 100,000 people [1]. Among trauma patients arriving at the emergency department (ED), the main cause of death during the first hour is haemorrhage, which is also responsible for almost half of deaths during the first 24 hours [7]. In trauma patients with active bleeding, control of the bleeding is the most essential intervention [8]. While sufficient and adequate bleeding control can increase survival rates [9], inadequate bleeding control can result in metabolic derangement and, eventually, death [8]. As the seriousness of RTA-related injuries can take time to manifest, it is crucial to stop any bleeding within the initial few minutes [10]. A randomised clinical trial compared the haemorrhage control skills (proper/correct use of tourniquet) of people who had received in-person training, those who had received instructional flashcards or audio kits with flashcards, and those without any training (control). It found the skills of those who had received in-person training were superior to the control, while people who received instructional flashcards or audio kits were no superior to the control [11]. While the ‘Stop The Bleed’ programme has spread worldwide, with 86,8511 participants in 119 countries [12], and the effectiveness of battlefield trauma management techniques in controlling bleeding has been well established by military research [10-11], the general public perception regarding bleeding control and the potential motivators for their willingness to act are unknown. Our aim is to evaluate options for enhancing community engagement and understanding of bleeding control methods, with the goal of empowering people to respond effectively to accidents and contribute to safer communities.

Methodology

This cross-sectional survey was conducted in Saudi Arabia, from February to July 2024, to determine the general public's understanding of bleeding management and its significance. A computerised survey was designed using "Google Forms TM", and the validated questionnaire was translated and evaluated by two expert emergency physicians prior to data collection. Upon approval from the Institutional Review Board (number 24-225), participants were recruited on a voluntary basis and asked to provide informed consent. They were then asked to complete an online questionnaire that was distributed via several social media platforms. A sample size of 392 was manually selected using "Epi Info TM" [15]. Eligible for inclusion were adult participants in Saudi Arabia who were over 17 years of age at the time of the research. Healthcare providers were included in the study. The questionnaire gathered participants' sociodemographic data (age, gender, occupation, educational status, etc.), their readiness to act in the event of a serious medical emergency, as well as information regarding perceived obstacles, comfort, mindset, and understanding of bleeding control. It also included a brief description of how to stop bleeding and tourniquet placement, and asked about participants’ willingness to participate in a future bleeding control campaign. Stata 17.0 software was utilised for data analysis.

Results

The total number of participants in the research was 392; Table 1 illustrates their demographics.

assistance in bleeding emergencies [21]. Moreover, the fear of contracting a blood-borne infection, the least cited concern (5.1%), posed high infection fears as a barrier to emergency assistance [22]. Surprisingly, the presence or absence of professional training did not markedly impact the participants' perception of these obstacles. This suggests that the decision to intervene might be driven more by individual psychological factors and the immediate assessment of the situation, rather than formal training. Our findings show no significant gender differences in emergency response behaviour, aligning with recent literature suggesting that gender may not be a reliable predictor of emergency intervention. This could challenge traditional perceptions of gender roles within the context of emergency assistance [23]. Contrary to our expectations that certified training would strongly indicate the likelihood of emergency intervention, our data revealed that educational level, and particularly a bachelor's degree, was a more significant factor, as shown by the statistically significant association. These findings suggest that the education system might play a crucial role in shaping individuals' readiness for emergency response, as has been identified in prior studies examining educational impact on health-related behaviours [24]. The low percentage of respondents with certified training (15.5%) indicates a need for policy intervention to improve access to, and incentives for, first aid training. Interestingly, the majority of those trained were bachelor's degree holders. This may reflect the broader trend of higher education institutions including or promoting such training, perhaps due to their resources and networks [22,23]. Moreover, our analysis revealed that respondents without prior training in bleeding control are significantly less likely to have previously assisted someone bleeding on the road. It must be emphasised, however, that our measure of past assistance does not equate to future behaviour. Nonetheless, past behaviour is often used as an indicator of future intentions; a component of the theory of planned behaviour [27]. Our study also sheds light on the readiness of individuals without formal training to improve their skills, with a significant number expressing interest in participating in educational workshops. Such inclination to learn could indicate a broader cultural shift towards proactive health and safety measures. This potential trend is mirrored by other studies that have observed an increase in public interest in first aid and emergency response education [25,26]. The findings of our study regarding tourniquet application reveal substantial variability in knowledge and use thereof, which is a point of concern given the critical role of tourniquets in haemorrhage control. Only a fifth (20.1%) of our participants believed tourniquets to be safe, suggesting a prevailing apprehension or misinformation about their usage. This is a significant finding, considering that previous research by Gardia et al. has shown the effectiveness of tourniquets, if applied correctly, in saving lives in cases of severe limb haemorrhage [30]. However, a majority of respondents reported applying the tourniquet directly on the wound (48.21%), which does not align with generally accepted best practices. As endorsed by trauma guidelines, the correct application of tourniquets involves placing them proximal to the bleeding site—on the limb between the wound and the heart—and not directly over the wound [31]. This misconception underscores a knowledge gap that can severely compromise the outcome of haemorrhage control efforts. A significant proportion of participants indicated that they would place the tourniquet before the bleeding site (37.24%); this aligns with correct tourniquet usage and can effectively stop life-threatening bleeding in extremity wounds [32]. However, the fact that a minority reported placing it below the wound (4.08%) or both above and below the wound (10.46%) further highlights the inconsistency and confusion regarding tourniquet placement. There are several limitations to this study that warrant consideration. First, the reliance on self-reported data may have introduced recall bias, as respondents might not accurately remember past events or their actions during emergencies. Second, the study's cross-sectional design limited our ability to assess changes over time and establish causal relationships. The use of a questionnaire also restricted the depth of understanding into the reasons behind individuals' willingness or lack thereof to control bleeding post-accidents, potentially overlooking nuanced factors influencing their responses. Additionally, the sample may not have been representative of the wider population due to the selection bias inherent in who chose to participate, which can affect the generalisability of the findings. Lastly, the study did not account for external factors such as accessibility to training or emergency medical supplies, which could significantly affect awareness and the willingness to act in a bleeding emergency.

Conclusion

This study evaluated the awareness and readiness of the community to respond to bleeding situations caused by motor vehicle accidents. A high number of respondents said they would likely act, which is consistent with previous research showing strong preparedness. However, anxieties regarding aggravating the injury, legal concerns, and discomfort at the sight of blood were important hurdles, emphasising the need for focused public education and legal protection. Notably, educational level, specifically a bachelor's degree, was a stronger predictor of intervention likelihood than certified training. Few respondents had received formal training, with the majority holding bachelor's degrees. Furthermore, there were significant knowledge gaps regarding tourniquet use, with only some participants believing them safe and many incorrectly applying them directly on the wound. The study's limitations include potential recollection bias, a cross-sectional design that limits causal conclusions, and selection bias, which affects generalisability. Future studies should consider interventions that address these concerns, as well as investigate the efficacy of first-aid education programmes. Overall, our findings highlight the importance of comprehensive public education and policy initiatives to improve community preparedness for emergency bleeding situations. Funding: No funding was received for this research. Conflict of Interest: The authors declare no conflict of interest. Ethical approval: This article does not include any studies by any of the authors involving human participants or animals.