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Communities affected by firearm injuries have lower rates of bystander interventions¹ and may mistrust first responders (FRs) (emergency medical services [EMS] and police).^2,3 A pilot session of a community-engaged, culturally adapted program (Working for Equity: WE Stop the Bleed [WE STB]²) demonstrated promise for increasing bystander bleeding control skills, improving self-efficacy⁴ for bleeding control, and building trust between community participants (CPs) and FRs in a Somali community in Seattle, Washington, affected by high rates of firearm-related deaths. We aimed to iteratively study this program to evaluate reproducibility of results and feasibility of program expansion with new participants within this community.

The WE STB program was implemented in person within the Seattle-area Somali community and included small group cultural exchange (Somali Health Board moderators) and the STB⁵ course (physician and FR instructors). Pilot program and conceptual model details were previously described.² The Somali Health Board recruited CPs through word of mouth and social media. First responders were recruited via emails to EMS and police leadership; all trained as STB instructors. Gift cards were offered for survey completion. English and Somali languages were used, with interpreters available. Programmatic changes and survey edits for clarity were iteratively implemented each session based on feedback (eMethods in Supplement 1). Race was self-reported by FRs to see how racial identity among FRs may or may not be representative of the communities they serve; CP surveys did not include race because all participants identified as part of the Somali community. Bleeding control knowledge and self-efficacy were evaluated (CPs only) using multiple-choice pre/post surveys. Trust and comfort between CPs and FRs were evaluated (both groups) through thematic analysis of open-ended survey responses. Acceptability was evaluated through willingness to recommend the program (both groups). Statistical significance was evaluated with a 2-tailed t test, with P < .05 indicating significance. This survey study follows the reporting guideline. The University of Washington institutional review board determined the study to be exempt because of minimal risk. Information regarding informed consent was written on the first page of the survey. Participants consented via completing the survey.

Three sessions with distinct participant groups were conducted in January 2020, June 2022, and July 2022 (95 CPs and 29 FRs [23 EMS and 6 police]). Survey response rates were 75% or greater for both groups. Participant characteristics are reported in Table 1. Community participant knowledge and self-efficacy improved from before to after the course (from 33% to 51% [P < .001] and from 77% to 97% [P < .001], respectively). Sixty-five of 67 CPs (97%) and 23 of 24 FRs (96%) would recommend the training to a friend or colleague. After course completion, 23 of 61 CPs (23%) still expressed concern they would be held responsible if they helped in an emergency and a bad outcome occurred.

Positive qualitative changes in comfort and trust were reported by FRs and CPs (Table 2). Most FRs (N = 16) reported the small group discussion and interactions as the best part of the training; CPs (N = 12) most frequently cited the hands-on training as their favorite. Substantive iterative changes based on feedback included moving small group discussion to the beginning of the session and shortening lecture time and increasing time teaching in small groups.

The results of this evaluation suggest that WE STB is a feasible and acceptable approach to increase bleeding control knowledge and self-efficacy among CPs and build trust and comfort between CPs and FRs.⁶ Iterative changes, specifically shifting time from lecture to small groups and doing small group discussion before the STB course, were key to program improvement. Evaluation survey translation introduced challenges with question fidelity and understanding, which likely contributed to lower scores on knowledge questions. All sessions were conducted within 1 geographic and cultural community; some adaptations may not be appropriate for other communities. Further evaluation of the WE STB program is currently under way with diverse US communities.

Accepted for Publication: May 29, 2024.

Published Online: September 11, 2024. doi:10.1001/jamasurg.2024.3372

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Stadeli KM et al. JAMA Surgery.

Corresponding Author: Kathryn M. Stadeli, MD, MPH, University of California, Davis, 2335 Stockton Blvd, Fifth Floor, Sacramento, CA 95817 (kmstadeli@ucdavis.edu).

Author Contributions: Dr Stadeli had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Stadeli, Vavilala.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Stadeli, Serrano, Vavilala.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Stadeli, Haji-Eda.

Obtained funding: Stadeli, Vavilala.

Administrative, technical, or material support: Stadeli, Mohamed, Agoubi, Dahiye, Vavilala.

Supervision: Stadeli, Vavilala.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Stadeli and Dr Serrano were supported by a training grant from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award T32DK07055. Dr Agoubi receives funding from grant T32HD057822 from the National Institute of Child Health and Human Development. Funding for the WE Stop the Bleed program was provided by a grant from the Seattle Medic One Foundation, Harborview Injury and Prevention Research Center, a grant from the Washington State Committee on Trauma, and a private donation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This paper was presented at the 2024 PCSA Annual Meeting; February 12, 2024; Rancho Mirage, California.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data Sharing Statement: See Supplement 2.

Additional Contributions: Eileen Bulger, MD, and Saman Arbabi, MD, MPH, Department of Surgery, University of Washington, Seattle, Maria Paulsen, RN, Harborview Medical Center, Seattle, Washington, Jeff Allen, MICP, NRP, Seattle Medic One, Seattle, Washington, provided invaluable contributions to and support of the STB program. They were not compensated for their work. The Somali Health Board, Seattle/King County EMS, and Seattle Police Department partnered on the STB program.