Hands off My Wife! Bahrain AED Survey Points to CPR Barriers

Shelley Wood

April 20, 2012

April 20, 2012 (Dubai, United Arab Emirates) — Controversial findings from a small, survey-based study conducted here in the Middle East suggest that Arab men would "not accept" men of certain other nationalities performing CPR, chest compressions, or exposing the chest area for the purpose of applying an automated external defibrillator (AED) on a female companion.

Orla Merrigan

Women surveyed, however, had no such concerns as to the race or sex of their rescuer.

"For the Middle East, my recommendation would be that female rescuers are acceptable to all sexes," lead author on the study, Orla Merrigan, an Irish nurse working at Royal College of Surgeons Ireland-Medical University of Bahrain, in Manama, told heartwire . "So maybe in shopping malls, for example, where they've trained male security guards [in AED usage], maybe they need to train female rescuers as well."

Merrigan presented the study here today at the World Congress of Cardiology (WCC) 2012. The idea for the study, she said, came from a similar survey conducted in Korea showing that many more men than women are surviving cardiac arrest. One explanation from the Korean group was that AEDs are used far less frequently in women than men, for cultural reasons.

"Would You Expose Your Female Relative's Chest Area?"

Merrigan's nursing students surveyed 229 males and 116 females over three days asking them general questions about AEDs as well as presenting them with different scenarios, including photographed vignettes, in which men or women of Arab, Indian, and European descent were shown readying a man or a woman for cardiopulmonary resuscitation (CPR) and application of an AED. Responders were asked if they would accept a man "exposing your female relative's chest area" to perform CPR, performing an electric shock, or applying chest compressions in public.

Survey scores were roughly the same in the scenarios where the man was the victim or when a woman was the victim with an Arab rescuer and when the woman was the rescuer. However, "if the victim was a Muslim female, a high percentage of [Arab] Muslim males would not allow an Indian male to expose the chest or provide CPR or an AED," Merrigan said. "When we questioned couples separately, the woman was quite happy to be rescued--she didn't care what nationality the rescuer was, they could do everything. But for males, they would not allow certain nationalities to help a woman in cardiac arrest."

Women, she added to heartwire , were shocked to hear their husbands' responses: "When we were doing these interviews with couples, the women were simply horrified that the man would let them die."

Male respondents were less concerned when the would-be rescuer was of European descent.

A Big Gap, Worth Filling

Merrigan points out that the recent CPR recommendations urge communities to look for "gaps and weaknesses" in their systems to better improve survival rates. "This is a big gap," she said. "We can always look at closing that."

AEDs, she noted, are rare in Bahrain, but "we have anecdotal evidence in Bahrain that when women have collapsed that people have not allowed them to receive CPR when the rescuers are male."

Several Gulf states and cities are stepping up requirements for AEDs in public places, including a Dubai plan to have AEDs on school buses. But even here, said Merrigan, problems could arise if an Indian male driver tried to apply the AED on a female student and a brother intervened. One solution she proposed to Dubai policy makers is to have female teaching assistants on the buses.

"Ethnicity has implications for the delivery and training of AED usage and the possible selection of who should be trained," she argued. "Arab countries may need to adapt new guidelines on the selection of rescuers to overcome this cultural barrier and improve the survival rate of out-of-hospital cardiac arrests. And any Arab country purchasing AEDs must ensure that a majority of female [emergency personnel] are also trained in AED use."

Explaining the Findings

A trio of Emirati women in hijab who spoke with heartwire after the session--but did not want to be named in the story--were dismissive of the results. One insisted that, faced with a real-life situation in which a female relative was in cardiac arrest, no man would refuse lifesaving assistance for his wife or sister, no matter who was providing it.

Another pointed out that Islam as it is practiced in the Gulf permits a woman to be uncovered when seeing her doctor, and in the scenario described, the bystander performing CPR would be a proxy for a physician.

Cardiologist Dr Said Mohamed Al-Hina (Diwan Medical Services, Muscat, Oman) also discounted the findings, pointing out that in life-and-death situations, practices that are haraam--forbidden--in Islam are permitted. "I'm a Muslim; if I am in a desert and there is no water, only alcohol, for my survival, my faith allows me to drink alcohol. If you tell me there is no food and to survive, I must eat pork; I don't eat pork, but in this situation I'm allowed. There are exceptions."

He believes Merrigan's findings are more revealing about the lack of knowledge of CPR and sudden cardiac death in the Gulf than they are about race, religion, or culture. "I don't think it is an issue of the ethnicity of the male, it is more the belief that no man should expose a woman's chest in public, even the husband."

He continued, "If they just see a man coming and trying to expose a woman's chest, they don't understand the benefit and what the dangers are if it is not done. I'm sure if you educate the people to a level similar to, say, the American level of the importance of AEDs, they would accept it."

Indeed, Merrigan's research also showed that two-thirds of people surveyed had never heard of an AED or how it was used and were unaware there was a device that could be used by a layperson to help someone in cardiac arrest.

Everywhere Has CPR Barriers

Following Merrigan's presentation, one of the moderators asked Dr Michael Sayre (Ohio State University, Columbus) if there were any comparable cultural barriers to CPR/AED use in the US. Sayre pointed to studies showing that CPR is much less common in poorer, often African American neighborhoods.

"I participated in a focus group with some of the neighborhoods in my city. In one neighborhood that has issues with violence, one comment was: 'I don't want to do CPR because I don't want to get shot.' That was really unlikely, but there was a perception that it was a problem."

Others said they don't feel safe among their neighbors and so wouldn't feel comfortable intervening and that is "a cultural issue that is probably similar to other countries."

A final factor, Sayre said, is that most Americans learn CPR at work. "So if you are living in a poor neighborhood, you are less likely to have a job and less likely to have been trained in CPR. So there could be several layers to the problem."