Public awareness about the emergency conditions and services provided by emergency medical services in the Northern Border Region of Saudi Arabia

Abstract

Background

Emergency Medical Services (EMS) are critical for prehospital care, yet their effectiveness can be undermined by inappropriate utilization and limited public recognition of true emergencies. This study assessed public knowledge of emergencies and EMS services in the Northern Border Region of Saudi Arabia.

Methods

A cross‑sectional online survey was conducted between May and December 2025 among adults aged 18–50 years residing in the Northern Border Region. A culturally adapted, previously validated 40‑item questionnaire was disseminated via social media to collect socio‑demographic data, assess EMS knowledge and practices, and evaluate responses to 24 hypothetical emergency and non‑emergency scenarios. Descriptive statistics, chi‑square/Fisher’s exact tests, and multiple logistic regression were used to examine factors associated with correct scenario‑based responses.

Results

A total of 1074 participants completed the survey; most were female (58.1%), Saudi nationals (92.5%), and aged 36–46 years (37.0%). Nearly all respondents (99.1%) reported they would call EMS for an unconscious person, and 99.0% correctly identified the EMS number (997). 99.6% knew that EMS both transports and treats patients, and 98.3% understood the dispatcher’s role in receiving calls and providing advice. Scenario performance was less consistent. While 92.3% correctly recognized an elderly patient with acute speech difficulty as an emergency, only 36.2% identified a 35‑year‑old woman with chest heaviness as an emergency. Conversely, 56.9% correctly classified a 30‑year‑old woman with lower abdominal pain and urinary symptoms as a non‑emergency, and only 0.09% recognized that a 4‑year‑old with a foreign body in the ear did not require EMS activation. Older age (≥46 years), female sex, lower education, retirement, Saudi nationality, residence in Arar, and no prior EMS call were independently associated with fewer correct responses (all p < 0.001).

Conclusion

In the Northern Border Region, basic EMS knowledge is high, but substantial gaps remain in recognizing specific emergency and non‑emergency conditions. Targeted public education focusing on symptom‑based emergencies and appropriate EMS utilization is needed to optimize EMS effectiveness and resource use.

Supplementary information

The online version contains supplementary material available at 10.1186/s12245-026-01153-w.

Introduction

Emergency Medical Services (EMS) are the first responders to serious medical emergencies and accidents, making them an essential component of the worldwide healthcare system [1, 2]. EMS is regarded as an essential element of worldwide healthcare [3]. There is high demand for emergency medical services worldwide [4]. Additionally, emergency rooms may become overcrowded due to excessive EMS utilization [5]. By providing timely, skilled patient care, EMS plays a key role in reducing morbidity and mortality associated with urgent illnesses [6, 7]. Misuse of EMS presents a significant global challenge [8]. Numerous examples of “unnecessary ambulance use” have been documented in Australia, South Africa, England, and Canada, with 16–51.7% of calls considered inappropriate [9, 10]. The Saudi Red Crescent Authority (SRCA) is primarily responsible for prehospital emergency response in Saudi Arabia [7]. The EMS system in Saudi Arabia largely follows the Anglo-American model, characterised by rapid patient transport to hospitals and prehospital care provided by qualified paramedics and emergency medical technicians [11]. Research on public knowledge of EMS services and their capabilities has been done in Saudi Arabia and other developing nations [12]. It offers free EMS services to residents, citizens, and visitors [13]. Furthermore, many individuals remain unaware of what constitutes an emergency and of EMS’s responsibilities, leading to calls to EMS for non-urgent cases [14]. Despite a recent study [15], there remains a lack of awareness regarding emergencies and the motivations behind EMS calls. Meanwhile, requests for EMS use have increased significantly in recent years [16].

In response to these challenges, national authorities and the SRCA have expanded ambulance coverage and dispatch capacity and have sought to enhance public awareness of the 997 number and the role of EMS through media, digital platforms, and community outreach [17]. Several regional and national surveys in Saudi Arabia have identified persistent gaps in public recognition of emergencies and appropriate EMS activation and have repeatedly recommended structured public education campaigns, school‑ and university‑based teaching, and collaboration with primary care to promote appropriate EMS use [12, 17]. However, there is still limited evidence on the implementation and effectiveness of these public awareness strategies, particularly in less densely populated regions such as the Northern Border Region. Therefore, it is crucial to evaluate the public’s awareness of emergencies and their understanding of EMS in this Region of Saudi Arabia.

Materials and methods

Study design & setting

A cross-sectional online survey was conducted between May and December 2025. among adults residing in the Northern Border Region of Saudi Arabia. This region is a sparsely populated area in the north of the country, including the cities of Arar, Rafha, Turayf, and Al‑Uwayqilah, with an estimated adult population of approximately 373,577 at the time of the study. The Saudi Red Crescent Authority (https://srca.org.sa/en/) primarily provides EMS in this region through a network of ground ambulances and dispatch centers covering urban and semi‑urban communities [18].

Eligibility criteria

The inclusion criteria comprised all adults aged 18 to 50 years who were currently living in any city or town within the Northern Border Region of Saudi Arabia and who consented to participate in this study. Exclusion criteria included adults who did not reside in the Northern Border Region, those under 18 years of age, and individuals who declined to participate in the survey.

Instrument used and data collection tool

A previously validated online survey [10, 12, 17] was used to assess public knowledge of emergencies and EMS services. It was modified to fit the culture of the Northern Border region of Saudi Arabia. The questionnaire consisted of three main parts, comprising 40 questions.

The first part focused on demographic characteristics (8 questions), where participants provided information on their age, gender, nationality, level of education, occupation, marital status, place of residence, and whether they had ever made an emergency service call.

The second part (24 questions), presented in Table 1, involved hypothetical emergency (n = 11) and non-emergency (n = 13) scenarios that were originally developed in Tehran, Iran, an Eastern Middle Eastern context with broadly similar cultural and legal restrictions regarding alcohol, and were adopted to allow international comparison of public recognition of emergencies. In line with the original instrument, the authors retained scenarios involving alcohol intoxication and alcohol‑related vomiting to reflect the fact that, despite legal prohibitions, EMS providers in Saudi Arabia may still encounter such presentations among residents and visitors. The scenario set primarily focused on medical and psychiatric emergencies, with only a limited number of injury‑related presentations (e.g., minor falls, burns, foreign body in the ear), and did not include high‑energy trauma such as road‑traffic collisions; this reflects the design of the original validated instrument rather than the relative importance of trauma in Saudi EMS practice. This section aimed to evaluate public awareness of the appropriate use of EMS services. For each scenario, participants were instructed to select one response from four options: (1) It is an emergency; I will call EMS, (2) It is an emergency, but I will not call EMS, (3) It is not an emergency, and I will not call EMS, or (4) It is not an emergency, but I will call EMS. Face and content validity were assessed by a panel of 10 experts, yielding item-level content validity indices (ICVI) and scale-level content validity indices (SCVI) greater than 0.80 [10]. The scenarios were translated into Arabic, the primary spoken language in Saudi Arabia, by two bilingual EMS providers familiar with both EMS practice and lay communication. During translation, potentially technical medical terms (e.g., ‘acute myocardial infarction’, ‘epileptic seizure’, ‘hypertension’) were systematically replaced with plain-language descriptions that reflect how such conditions are commonly described by the general public (e.g., ‘sudden severe chest pain’, ‘fit/convulsion’, ‘high blood pressure’), while preserving the clinical meaning of each scenario. The Arabic version was then back‑translated into English and reviewed by the original questionnaire developers and the expert panel to confirm that the simplified wording accurately captured the intended clinical situations without introducing additional medical jargon. In the pilot test (n = 10), participants were specifically asked whether any scenario wording was unclear or “too medical”; no major comprehension problems were reported, and minor wording refinements were made to enhance clarity for non‑medical participants further. (Additional File 1) https://drive.google.com/file/d/1RzDom9t9U1FjIsolYJPFmJ0XT_D5Y4lb/view?usp=drive_link

Table 1.

List of emergency and non-emergency scenarios given to the participants

Scenarios Number	Scenarios description
1	A forty-year-old guy who has had colon cancer in the past is in excruciating agony and needs medication.
2	Sudden dizziness strikes a woman in her 40s who has a known history of hypertension.
3	A woman in her 30s presents with lower abdominal discomfort, dysuria, and increased urinary frequency.
4	When intoxicated, speaking is difficult and incoherent for a 77-year-old.
5	A woman with diabetes experiences appetite loss and stomachache. She has a blood sugar level of 350 and is somewhat lethargic.
6	A death and transfer certificate is required for a 70-year-old man who, with his doctor’s approval, died at home last night.
7	The three-year-old sustained a ping pong ball-sized bruising after falling off the bench.
8	A lady who is eight months pregnant believes that there are abnormal fetal movements.
9	Your two-year-old has bruises around his lips, his voice is raspy, and he is sobbing and dribbling from the corner of his mouth, all signs of a cold.
10	An 18-year-old male with known depression appears drowsy this morning and opens his eyes only in response to verbal stimuli.
11	A six-year-old child with known epilepsy presented with a seizure episode.
12	During a family picnic, your 10-year-old son suddenly develops urticarial wheals.
13	Two hours postprandially, a woman aged 29 had diarrhea, vomiting, and a stomachache.
14	A girl aged 19 with a background of anxiety and mental health disorders is currently refusing both food and her medications.
15	A woman aged 35 who has never experienced heart issues feels as though her chest is heavy.
16	A 4-year-old child has consumed ten 500 mg acetaminophen tablets.
17	Knee discomfort and edema are being experienced by a woman aged 87 who has been previously diagnosed with arthritis.
18	A forty-year-old woman’s hand was sprayed with boiling water, causing her skin to become red and badly.
19	A 4-year-old child inserted a small object into his ear.
20	A man aged 25 is throwing up after drinking alcohol.
21	A two-year-old has consumed an unknown medication.
22	A woman aged 45 with a history of hypertension is asymptomatic, and her blood pressure is 90/160 on routine daily measurements.
23	A person with a mobility impairment requires assistance with ambulation.
24	A man aged 40 who has had back pain for six months has typical back discomfort. He has run out of painkillers and wakes up during the night due to this ache.

The third part (8 questions) assessed participants’ knowledge of EMS, including awareness of the emergency contact number, the role of the dispatcher, the services provided by EMS, and participants’ practices related to EMS utilization. The internal consistency of the knowledge questionnaire was evaluated using Cohen’s kappa, yielding a value of 0.773, indicating substantial agreement [12].

Sample size

The minimum required sample size was estimated using Raosoft online calculator (Raosoft, Inc., Seattle, WA, USA). Assuming a 95% confidence level, 5% margin of error, and a conservative anticipated proportion of 50% for adequate EMS awareness (to maximize the sample size) in the adult population of the Northern Border Region, the calculated minimum sample size was 384 participants. To improve precision and enable subgroup analyses by socio‑demographic characteristics, we continued recruitment beyond the minimum and ultimately obtained 1074 completed responses.

Ethical considerations

Participants’ anonymity was crucial because no identities or personally identifiable information were collected during data collection. This method ensured each participant’s privacy and anonymity, enabling honest and objective responses without concerns about repercussions to their personal or professional lives. Before completing the online survey, each participant gave their informed consent. Participants could decline or withdraw from the survey at any time without facing consequences, as the invitation clearly stated that participation was entirely voluntary. No personally identifiable information was collected, and the confidentiality of responses was preserved. Ethical approval was granted by the local bioethics committee at Northern Border University (HAP-09-A-043) to ensure adherence to the highest ethical standards in research (Protocol number: 42/25/H).

Statistical analysis

The frequency and percentage were used to describe the collected data. (Additional File 2). https://docs.google.com/spreadsheets/d/1_epeymmg-bbburIux5dPe5WTFoY4ERTP/edit?usp=drive_link%26ouid=100710570988282580749%26rtpof=true%26sd=true

The Chi-square test and Fisher’s Exact test were utilized to compare categorical data, as appropriate. Multiple logistic regression was employed to identify significant predictors for correct responses to the proposed scenarios. Statistical significance was set at a p-value < 0.05. Statistical analysis was performed using the computerised statistical package STATA/SE version 11.2 for Windows (STATA Corporation, College Station, Texas) and Microsoft Excel.

Results

Table 2 presents the socio-demographic characteristics of the study population (n = 1,074). The highest proportion of participants was aged 36–46 (36.96%), followed by those aged 46+ (32.03%). Females comprised a larger proportion of the sample (58.1%) than males (41.9%). Most respondents were Saudi nationals (92.46%). 77.37% of the total participants were married. Regarding educational level, the majority had completed secondary school (69.37%), while 30.63% held a university degree or higher. In terms of occupation, employees accounted for 29.43% of participants, whereas 31.56% were retired and 22.44% were students. Most of the participants resided in Arar (92.36%). About 90.5% of the participants reported having previously called EMS to request an ambulance.

Table 2.

Socio-demographic characteristics of the study population (n = 1,074)

Variable		No.	%
Age (years)	18–25	250	23.28
	26–35	83	7.73
	36–46	397	36.96
	More than 46	344	32.03
Sex	Male	450	41.90
	Female	624	58.10
Nationality	Saudi	993	92.46
	Non-Saudi	81	7.54
Marital status	Married	831	77.37
	Single	243	22.63
Educational level	University or higher	329	30.63
	Secondary school	745	69.37
Occupation	Employee	316	29.43
	Retired	339	31.56
	Student	241	22.44
	Not working	178	16.57
City	Arar	992	92.36
	Other	82	7.64
Have you ever called the EMS and asked for an ambulance?	Yes	972	90.50
	No	102	9.50

Data are presented as numbers (No.) and percentages (%)

Table 3 illustrates participants’ knowledge and practices regarding emergency medical services (EMS) in the Northern Border Region of Saudi Arabia (n = 1,074). Nearly all participants (99.07%) reported that they would call emergency response services when encountering an unconscious person. The majority correctly identified the EMS contact number (98.98%) and recognized that EMS is responsible for both transferring and treating patients (99.63%). Likewise, 98.32% accurately understood that the dispatcher’s role includes receiving calls and providing medical advice. Regarding behavior when approached by an ambulance, 61.08% stated they would immediately get out of the way, while 38.83% would only do so if the ambulance’s lights were on. Most participants (98.98%) believed that 10 minutes was the expected EMS response time to emergencies, and 89.29% considered the current response time in their area appropriate. 82.22% indicated that they would interfere and help if given permission when encountered by EMS personnel.

Table 3.

Knowledge and practices towards emergency medical services among the population in the Northern Border Region, Saudi Arabia (n = 1,074)

Variable		No.	%
To provide First Aid to an unconscious Person. What do you do?	Call the emergency response services	1064	99.07
	Try to awaken the person	9	0.84
	Shift to the nearby hospital	1	0.09
EMS Contact number? Which one of those is	996	5	0.47
	997	1063	98.98
	998	2	0.19
	999	4	0.37
Which Services are Offered by EMS?	Patient transfer only	4	0.37
	Transferring and treating the patient	1070	99.63
What is the role of a Dispatcher in EMS?	Receive call only	12	1.12
	Receiving calls and providing medical advice	1056	98.32
	I do not know	6	0.56
What should you do when an ambulance approaches you while driving?	Immediately get out of the way	656	61.08
	Move out of the way only if lights are on	417	38.83
	Move only if SRC is behind me	1	0.09
What is your opinion about EMS response time to arrive in an emergency?	10 minutes	1.063	98.98
	30 minutes	3	0.28
	15 minutes	3	0.28
Is the ambulance response time in your area appropriate?	Yes	959	89.29
	No	100	9.31
	I do not know	15	1.40
What are your actions when encountering EMS?	Stay away	188	17.50
	Interfering and helping them with permission	883	82.22
	Just watching	3	0.28

Data are presented as numbers (No.) and percentages (%)

Table 4 presents participants’ responses to 24 hypothetical scenarios assessing their knowledge and decision-making regarding EMS use (n = 1,074). In emergency scenarios, 92.27% of participants correctly identified that a 77-year-old experiencing difficulty speaking and slurred speech was an emergency and indicated they would contact EMS. In contrast, only 36.22% recognized that a 35-year-old woman with mild chest heaviness and no history of heart problems also constituted an emergency and needed EMS. As for non-emergency scenarios, A woman in her 30s presents with lower abdominal discomfort, dysuria, and increased urinary frequency was correctly identified by 56.89% as a non-emergency situation that did not require emergency medical services (EMS). In contrast, only 0.09% correctly identified a child aged 4 who inserted a small object into his ear as a non-emergency situation that did not require EMS.

Table 4.

Knowledge and practice for hypothetical scenarios or conditions among the population in Northern Border Region, Saudi Arabia (n = 1,074)

Scenarios Number	It’s an emergency				This situation is non-emergent
	I will call EMS		I won’t call EMS		I won’t call EMS		I will call EMS
	No.	%	No.	%	No.	%	No.	%
1	627	58.38	3	0.28	3	0.28	441	41.06
2	897	83.52	177	16.48	0	0.00	0	0.00
3	113	10.52	247	23.00	611	56.89	103	9.59
4	991	92.27	7	0.65	0	0.00	76	7.08
5	731	68.06	108	10.06	3	0.28	232	21.60
6	219	20.39	3	0.28	8	0.74	844	78.58
7	955	88.92	11	1.02	106	9.87	2	0.19
8	651	60.61	83	7.73	106	9.87	234	21.79
9	980	91.25	9	0.84	82	7.64	3	0.28
10	625	58.19	440	40.97	8	0.74	1	0.09
11	557	51.86	77	7.17	4	0.37	436	40.60
12	307	28.58	574	53.45	14	1.30	179	16.67
13	874	81.38	9	0.84	84	7.82	107	9.96
14	539	50.19	9	0.84	105	9.78	421	39.20
15	389	36.22	7	0.65	1	0.09	677	63.04
16	878	81.75	194	18.06	1	0.09	1	0.09
17	190	17.69	5	0.47	110	10.24	769	71.60
18	1,056	98.32	9	0.84	6	0.56	3	0.28
19	726	67.60	5	0.47	1	0.09	342	31.84
20	21	1.96	83	7.73	452	42.09	518	48.23
21	552	51.40	80	7.45	4	0.37	438	40.78
22	300	27.93	348	32.40	88	8.19	338	31.47
23	296	27.56	12	1.12	193	17.97	573	53.35
24	345	32.12	194	18.06	17	1.58	518	48.23

Data are presented as numbers (No.) and percentages (%). Bold values = correct answers

Table 5 presents the associations between the number of correct responses to hypothetical emergencies and participants’ socio-demographic characteristics. Significant associations were observed with participants’ age: those aged 36–46 years had the highest proportion of respondents with more than 8 correct answers, while participants aged 46+ accounted for 50.45% of those with 8 or fewer correct answers (p < 0.001). Females accounted for the majority of participants with fewer than eight correct answers, whereas males comprised more than half of those with over eight correct answers (p < 0.001). A higher number of correct answers was also significantly associated with having a university education or higher (p < 0.001). Most participants with more than eight correct answers were employed (77.23%), while over half of those with eight or fewer correct answers were retired (p < 0.001). Additionally, significant associations were found between the number of correct answers and participants’ nationality, marital status, city of residence, and prior experience calling EMS to request an ambulance (all p < 0.001).

Table 5.

Variations in knowledge and practice answers for the emergency hypothetical scenarios or conditions by socio-demographic characteristics of the study population (1,074)

Variable		Correct knowledge and practice answers				X2	P
		≤ 8 answers (n = 670)		>8 answers (n = 404)
		No.	%	No.	%
Age (years)	18–25	231	34.48	19	4.70	647.21	<0.001
	26–35	3	0.45	80	19.80
	36–46	98	14.63	299	74.01
	More than 46	338	50.45	6	1.49
Sex	Male	234	34.93	216	53.47	35.59	<0.001
	Female	436	65.07	188	46.53
Nationality	Saudi	670	100.00	323	79.95	145.29	<0.001
	Non-Saudi	0	0.00	81	20.05
Marital status	Married	437	65.22	394	97.52	150.20	<0.001
	Single	233	34.78	10	2.48
Educational level	University or higher	7	1.04	322	79.70	733.83	<0.001
	Secondary school	663	98.96	82	20.30
Occupation	Employee	4	0.60	312	77.23	816.72	<0.001
	Retired	337	50.30	2	0.50
	Student	230	34.33	11	2.72
	Not working	99	14.78	79	19.55
City	Arar	670	100.00	322	79.70	147.23	<0.001
	Other	0	0.00	82	20.30
Have you ever called the EMS and asked for an ambulance?	Yes	666	99.40	306	75.74	164.15	<0.001
	No	4	0.60	98	24.26

X²: Chi-square test statistics, P: Probability, statistical significance was set at p < 0.05

Discussion

Emergency Medical Services are a vital component of contemporary healthcare systems, serving as the first point of contact for patients with acute, life-threatening conditions. In recent years, Saudi Arabia has significantly invested in strengthening its emergency healthcare infrastructure by expanding ambulance networks, improving dispatch centers, adopting digital triage systems, and enhancing personnel training. Despite these initiatives, the effective utilization of EMS services still largely depends on the public’s understanding of when and how to access them. International literature consistently demonstrates that limited public awareness can lead to delayed EMS activation, misuse of emergency numbers, inappropriate self-transport to hospitals, and increased morbidity in time-critical situations such as myocardial infarction, stroke, trauma, and respiratory emergencies. Therefore, this cross-sectional study aims to evaluate public awareness, attitudes, and utilization patterns of Emergency Medical Services among residents of the Northern Border Region in Saudi Arabia. It investigates demographic predictors, common misconceptions, and overall readiness to activate EMS. Overall, the findings indicate a high level of basic awareness among participants. Specifically, 98.98% correctly identified the EMS contact number, 99.63% understood that EMS is responsible for both treating and transporting patients, and 99.07% stated they would call EMS if they encountered an unconscious individual. These findings align with results from an Indian study, in which 76.2% of respondents were aware that ‘108’ is the number to call in the event of a medical emergency, while more than one‑quarter of participants were unaware of the correct EMS number [4]. Conversely, a study in Riyadh, Saudi Arabia, revealed a deficiency in Community awareness, with only 38.5% correctly recalling the emergency medical services telephone number [19].

Despite this high overall awareness, significant gaps remain in recognizing less-obvious emergency scenarios. For example, although 92.27% of participants correctly identified an elderly patient with slurred speech as an emergency, only 36.22% recognized that mild chest heaviness in a young woman required EMS intervention. Additionally, all participants considered a child inserting a toy into the ear an emergency, even though it did not necessarily require EMS activation. Similarly, an Australian study reported that all participants would call EMS [9]. These patterns highlight potential misuse or overuse of EMS resources, and similar challenges have been observed in Western Saudi Arabia, underscoring the need for targeted educational interventions [6]. These differences in recognizing crises and non-emergencies across societies underscore the importance of targeted public education initiatives to raise awareness of the various circumstances, especially those most common in each community. These results are relevant to previous research in Saudi Arabia (Table 6). Another study in India revealed a large public knowledge gap, with 56.7% of the survey population unaware of EMS [20]. This highlights the need for public awareness and education as a crucial element of EMS development [21, 22].

Table 6.

Summary of previous studies related to public awareness of emergency medical services and public education initiatives in Saudi Arabia

Primary Author (et al.)	Year	Region in KSA	Sample Size	Study Type/Data Collection	Relevance to Current Study	Public education initiatives
Group ETEMSAT et al. [6].	2015	Western Region (Jeddah)	1534	Interviewer-administered questionnaire	Foundational early assessment of EMS awareness.	One of the earliest reports to identify poor public awareness of EMS in Western Saudi Arabia and explicitly advocate mass‑media and school‑based educational programs
Alanazy A et al. [12].	2024	Eastern Region	435	Online cross-sectional survey	Highlights knowledge gaps and community attitudes toward EMS.	Highlighted the need for targeted public education and collaboration with the Saudi Red Crescent Authority (SRCA) to improve EMS activation, but did not evaluate specific campaigns
Binhotan MS et al. [17].	2025	Riyadh	522	Cross-sectional survey (paper + digital distribution)	Updated insights on emergency recognition; useful regional comparison.	Documented knowledge gaps and recommended community education and media campaigns; no formal evaluation of implemented strategies was reported
Alabdali AA et al. [19].	2021	Riyadh	4806	Semi-structured in-person survey	Large sample; strong evidence for awareness gaps.	Large in‑person survey; authors called for public awareness campaigns and school‑based education regarding EMS numbers and indications for use.
Aljabri D et al. [24].	2022	Nationwide	805	Bilingual online survey	National benchmark for EMS number awareness and usage patterns. Public knowledge of EMS responsibilities and correct emergency procedures was documented.	Assessed use of the 997 mobile number during COVID‑19 and described increased exposure through pandemic‑related media messaging as a possible driver of improved awareness.
Altherwi TI et al. [25].	2021	Jazan Region	427	Online questionnaire	Examines EMS activation in specific emergencies; comparable to underserved regions.	Recommended structured community outreach and collaboration with primary care for acute myocardial infarction recognition and rapid EMS activation

In the Saudi context, trauma represents a major cause of morbidity and mortality and constitutes a substantial proportion of EMS workload, particularly through road-traffic collisions and fall-related injuries [23]. However, the scenario set used in the present study, inherited from the original validated instrument, primarily emphasized medical and psychiatric emergencies and included only a limited number of injury-related presentations (such as minor falls and burns), without explicitly representing high-energy trauma. This imbalance reflects the design of the source questionnaire rather than the relative importance of trauma in Saudi Arabia. It suggests that future research should incorporate a broader range of trauma scenarios to assess public decision-making regarding EMS activation for injury-related emergencies.

Across Saudi Arabia, EMS development has been accompanied by efforts to raise public awareness of the 997 number and the SRCA’s role [19, 24]. Several regional and national surveys (Table 6) have not only quantified awareness gaps but also recommended concrete public education strategies, including mass‑media campaigns, social media messaging, school and university programs, and collaboration with primary care and community organizations. For example, studies from Riyadh [17, 19], the Eastern Region [12], Jazan [25], and Western Saudi Arabia [6] have consistently advocated targeted education on symptom‑based emergencies such as acute chest pain and stroke, as well as guidance on non‑emergency conditions that can be safely managed without EMS activation.

Despite these recommendations, the published literature from Saudi Arabia provides limited empirical evaluation of the effectiveness of specific public education initiatives [24]. Some nationwide work during the COVID‑19 pandemic suggests that intensive media coverage and governmental messaging may have contributed to increased recognition and use of the 997 number. Still, formal pre- and post-assessments of EMS campaigns remain scarce. Our findings from the Northern Border Region, with high basic knowledge of EMS functions yet substantial misclassification of certain emergency and non‑emergency scenarios, indicate that existing awareness activities, if present, have not fully addressed more nuanced decision‑making about when to activate EMS. This underscores the need for structured, evaluated public education programs that move beyond simply promoting the emergency number to focus on scenario‑based decision support and appropriate resource use.

Socio-demographic factors were significantly associated with EMS knowledge. Participants aged 36–46 years accounted for the largest proportion of those who answered more than 8 correct answers in the emergency scenarios. In contrast, individuals aged 46 or older accounted for 50.45% of those with eight or fewer correct responses. These findings align with a study that found older participants were poor predictors of EMS [26, 27]. In addition, this suggests that younger generations are more receptive to information from a variety of sources, including social media [12, 28]. Males achieved higher knowledge scores than females, and university-educated and employed respondents performed better than those with lower educational levels and retired participants. These findings align with other studies demonstrating a significant association between male gender and appropriate ER visits, suggesting improved emergency case identification [26], even though age was not shown to affect emergency case recognition [9]. These results are consistent with previous studies and underscore the importance of ongoing education [6, 10]. This contrasts with a study that showed low awareness among males [28, 29].

Regarding response time expectations, most participants reported that an EMS arrival time of 10 minutes was acceptable, and 89.29% considered the current response time in their area appropriate. Another study found that perceived EMS response time exceeded actual response time, with low correlation [30]. This contrasts with studies from the Eastern Region, where public expectations of EMS arrival were often longer, sometimes exceeding 30 minutes [6]. Additionally, patients’ estimated response times were usually longer than the actual response times in Addis Ababa, Ethiopia [31]. This indicates that longer response times naturally result in much higher death rates, whereas shorter response times are strongly associated with higher survival rates for victims of traffic accidents [31, 32].

Limitations

Several limitations should be acknowledged. First, the study relied on self-reported data, which can introduce recall and social desirability biases. Second, the cross-sectional design prevents causal inference about the relationship between demographic factors and EMS knowledge. Third, the hypothetical scenarios used may not accurately reflect actual behavior in real emergencies, and some items (such as alcohol‑related presentations) may have been less familiar in a predominantly alcohol‑restricted setting, even though such cases remain operationally relevant for EMS providers. In addition, because the scenarios were adopted from a previously validated instrument rather than specifically constructed for the Saudi context, the case mix may have introduced selection bias toward certain medical conditions while under‑representing others. Moreover, the scenario set contained relatively few high‑severity trauma cases, which may limit inferences about public recognition of injury‑related emergencies despite the high national burden of trauma and trauma‑related EMS activations in Saudi Arabia. Additionally, although the scenarios underwent forward–backward translation, expert review, and pilot testing to ensure cultural and linguistic appropriateness, some residual medical terminology may still have been challenging for participants with lower levels of education. This could partly explain the poorer performance in certain scenarios and suggests that even more simplified, narrative‑style descriptions may be required in future community surveys. Fourth, the sample was predominantly female and residents of Arar, potentially limiting the applicability of these findings to other geographic regions. Fifth, our findings cannot be extrapolated to real-world circumstances because most participants had formal education, and there was limited information on those without it. Lastly, prior formal EMS or first-aid training was not evaluated, which could have influenced participants’ responses and knowledge levels.

Community emergency context

Emergency Medical Services serve as a critical interface between the community and the healthcare system, particularly in geographically vast, sparsely populated regions such as the current region. In this context, community members are often the first to recognize acute symptoms, decide whether a situation constitutes an emergency, and choose whether to activate EMS, self‑transport to a hospital, or delay care [33].

The present study highlights that, while basic knowledge of EMS functions and contact numbers is high, substantial uncertainty persists regarding which community‑level conditions truly warrant EMS activation, including atypical chest pain, minor trauma, and common non‑emergency complaints. Strengthening community emergency preparedness, therefore, requires not only maintaining robust EMS infrastructure but also equipping laypersons with practical, scenario‑based guidance on when and how to engage EMS, how to provide simple first aid while waiting for help, and how to avoid unnecessary ambulance use for non‑urgent conditions [34, 35]. Involving schools, workplaces, and local organizations in community emergency education may foster shared responsibility for early recognition and appropriate activation of EMS, ultimately improving outcomes for time‑sensitive conditions [36, 37].

Figure 1 presents a conceptual framework synthesizing the community emergency recognition and EMS activation pathway based on our findings. The diagram illustrates that despite high baseline knowledge of EMS contact information and functions, critical gaps in scenario-based recognition create two divergent pathways: appropriate EMS activation leading to optimal outcomes, and recognition errors leading to delayed care or resource misuse. The framework highlights multiple intervention points where targeted public education, delivered through mass media, schools, workplaces, and primary care partnerships, can strengthen community emergency preparedness and optimize EMS utilization.

Fig. 1.

Conceptual framework for community emergency recognition and EMS activation pathway in the local region

Recommendations and implications

Aligning public expectations with realistic operational performance through educational campaigns may further enhance satisfaction and trust in EMS services. Tailored educational programs, scenario-based public awareness campaigns, and increased opportunities for community engagement with EMS can improve decision-making, optimize resource utilization, and strengthen community trust in prehospital care. Given the limited empirical evaluation of existing awareness initiatives in Saudi Arabia, future efforts by SRCA and regional health authorities should go beyond simply promoting the 997 number. They should include rigorously evaluated, scenario‑focused interventions (e.g., campaigns addressing chest pain, stroke, minor trauma, and other commonly misclassified conditions) delivered through mass media, social media, schools, and primary care settings.

Conclusion

The findings of the current study highlight the prevalence of unidentified emergency conditions and the need for greater public awareness of EMS services in the Northern Border Region of Saudi Arabia. EMS knowledge was significantly affected by age, education, gender, and place of residence. Overall, while basic awareness and intended behaviors towards EMS are strong, important gaps remain in recognizing atypical emergencies and distinguishing non-emergency situations. These gaps may lead to delayed activation for time-sensitive conditions and to unnecessary EMS use for minor complaints.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

SEE conceived and designed the study, supervised data collection, and critically revised the manuscript. F.N.S.A., F.S.F.A., A.Z.M.A., R.F.A.A., Y.F.A.A., F.S.F.A and Y.M.M.A. (students) participated in data collection, data entry, and initial analysis. HEB, EKF, MSF, and BAA performed data analysis and interpretation and drafted the manuscript. SEE, HEB, EKF, MSF, and BAA provided overall supervision, contributed to the study design and interpretation of findings, edited the manuscript, and provided final approval of the version to be published. All authors read and approved the final manuscript.

Funding

Not applicable.

Data availability

The data collected for the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

”This study was approved by the Local Committee of Bioethics (HAP-09-A-043) at the Northern Border University in Saudi Arabia, decision no.) 42/25/H (on 22/05/2025, concerning the approval of applying for this research. The study was conducted in accordance with the ethical standards laid down by the Declaration of Helsinki”. “Oral and written informed consents were obtained from all participants prior to their participation. All participants were informed that participation is completely voluntary, and data collectors introduced and explained the research to participants”.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.