Methodological analysis of a community-based training initiative using the EPIS framework: An ongoing initiative to empower 10 million bystanders in CPR and bleeding control

Asma Altaf Hussain Merchant, Sheza Hassan, Noor Baig, Huba Atiq, Sana Mahmood, Ann Doll, Rizwan Naseer, Zia Ul Haq, Deeba Shehnaz, Adil H. Haider, Junaid Razzak

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)


Background Out-of-hospital cardiac arrest (OHCA) and life-Threatening bleeding from trauma are leading causes of preventable mortality globally. Early intervention from bystanders can play a pivotal role in increasing the survival rate of victims. While great efforts for bystander training have yielded positive results in high-income countries, the same has not been replicated in low and middle-income countries (LMICs) due to resources constraints. This article describes a replicable implementation model of a nationwide program, aimed at empowering 10 million bystanders with basic knowledge and skills of hands-only cardiopulmonary resuscitation (CPR) and bleeding control in a resource-limited setting. Methods Using the EPIS (Exploration, Preparation, Implementation and Sustainment) framework, we describe the application of a national bystander training program, named Pakistan Life Savers Programme (PLSP)', in an LMIC. We discuss the opportunities and challenges faced during each phase of the program's implementation and identify feasible and sustainable actions to make them reproducible in similar low-resource settings. Results A high mortality rate owing to OHCA and traumatic life-Threatening bleeding was identified as a national issue in Pakistan. After intensive discussions during the exploration phase, PLSP was chosen as a potential solution. The preparation phase oversaw the logistical administration of the program and highlighted avenues using minimal resources to attain maximum outreach. National implementation of bystander training started as a pilot in suburban schools and expanded to other institutions, with 127 833 bystanders trained to date. Sustainability of the program was targeted through its addition in a single national curriculum taught in schools and the development of a cohesive collaborative network with entities sharing similar goals. Conclusion This article provides a methodological framework of implementing a national intervention based on bystander response. Such programs can increase bystander willingness and confidence in performing CPR and bleeding control, decreasing preventable deaths in countries having a high mortality burden. Level of evidence Level VI.

Original languageEnglish
Article numbere001132
JournalTrauma Surgery and Acute Care Open
Issue number1
Publication statusPublished - 14 Nov 2023


  • heart arrest
  • public health
  • wounds and injuries


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