Bystanders’ attitudes towards drone delivered Automated External Defibrillators for out-of-hospital cardiac arrest: A qualitative interview study

Celia J. Bernstein; Christopher M. Smith; Carl Powell; Mary O’Sullivan; Mark Holt; Keith Couper; Nigel Rees

doi:10.1371/journal.pone.0337082

Peer Review History

Original SubmissionJuly 11, 2025
23 Sep 2025 Decision Letter - Nik Hisamuddin Nik Ab. Rahman, Editor Dear Dr. Smith, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Nov 07 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. 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You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. We will update your Data Availability statement on your behalf to reflect the information you provide. 3. In the online submission form, you indicated that the anonymised transcripts generated during the current study and our analyses of them are stored securely at the host institution and are available from the corresponding author on reasonable request. Due to the risk of participant identification we will not share interview recordings. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. 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He is also Assistant Director for Research & Innovation for Welsh Ambulance Services University NHS Trust. We note that you received funding from a commercial source: [Name of Company] Please provide an amended Competing Interests Statement that explicitly states this commercial funder, along with any other relevant declarations relating to employment, consultancy, patents, products in development, marketed products, etc. Within this Competing Interests Statement, please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include your amended Competing Interests Statement within your cover letter. We will change the online submission form on your behalf. 5. Thank you for stating the following financial disclosure: This study was funded by the National Institute for Health and Care Research (NIHR) under its Research for Patient Benefit programme (Grant Reference Number NIHR204382) and Health and Care Research Wales (IRAS: 318417). The views expressed are those of the author(s) and not necessarily those of the NIHR, the Department of Health and Social Care or Health and Care Research Wales. Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 6. Please amend your authorship list in your manuscript file to include author Christopher Matthew Smith, Celia J Bernstein, Carl Powell, Mary O'Sullivan, Mark Holt , Keith Couper, Nigel Rees. 7. Please amend the manuscript submission data (via Edit Submission) to include author Bernstein, C J, Smith, C M, Powell, C, O’Sullivan, M, Holt, M, Couper, K, Rees, N. 8. Please remove all personal information, ensure that the data shared are in accordance with participant consent, and re-upload a fully anonymized data set. Note: spreadsheet columns with personal information must be removed and not hidden as all hidden columns will appear in the published file. 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If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: N/A Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: No Reviewer #2: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The investigators explored public attitudes towards drone-delivered AEDs for OHCA by conducting 14 semi-structured interviews with real-life OHCA bystanders. They identified 5 themes and devised interventions. 1. The sample size is small and it is unclear whether the subjects are representative of the general population. Nevertheless, the study provides clues on the complexity of the process. I suggest that the authors acknowledge the small sample size in the limitations section. 2. The availability of AED doesn’t guarantee it being used. I would cite the Home use of AED trial (HAT), which did not improve the OHCA outcomes (DOI: 10.1056/NEJMoa0801651). One of the reasons for failure was insufficient use of the AEDs, despite resuscitation training, including AED, provided to the caregivers in the study. 3. OHCA outcomes are better when the resuscitation response is integrated. Incorporation of drone-delivered AEDs require an integrated response from multiple stakeholders, including resuscitation services, drone operators, regulators, call handlers, CPR training providers. I would cite this paper (DOI: 10.1016/j.resuscitation.2016.10.029), tying the positive outcomes to integration of resuscitation response. Reviewer #2: This is a well-conducted and timely qualitative study exploring bystanders’ perspectives on drone-delivered AEDs in OHCA. It makes an important contribution to understanding public acceptance and barriers to implementation of emerging prehospital technologies. Strengths: Clear use of theoretical frameworks (TDF, COM-B, Behaviour Change Wheel) to guide analysis and intervention development. Rich participant data, with well-chosen illustrative quotes. Identification of practical intervention areas (call-handler scripts, training, co-responder models) with real-world applicability. Transparent reporting following COREQ guidelines. Suggestions for minor revision: 1) Data availability statement: Clarify that anonymised transcripts are available on request because of participant confidentiality, as PLOS requires explicit justification for restrictions. 2) Methods – saturation: Expand on how thematic saturation was determined (e.g., what criteria were used at 14 interviews to conclude no new insights were emerging). 3) Transferability of findings: Consider discussing how perceptions of drone technology may vary internationally and whether the UK-specific context (regulation, AED availability) limits generalisability. 4) Limitations: Expand slightly on the possible impact of self-selection bias (motivated or more confident bystanders may have been overrepresented) and the exclusion of suspected fraudulent respondents. 5) Language/clarity: Minor editorial corrections (e.g., sentence flow in Background and Discussion) will improve readability. Overall, this is an important and well-executed manuscript that will interest both emergency medicine and health policy audiences. I recommend acceptance after minor revisions. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No Reviewer #2: Yes: Jahed Hossain Nobel ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org https://doi.org/10.1371/journal.pone.0337082.r001
Revision 1
3 Nov 2025 Author Response Response to reviewers Thank you for your review of the manuscript, and for the opportunity to resubmit. We hope the changes that we have made have resulted in an improved manuscript. Comments to the Author Have the authors made all data underlying the findings in their manuscript fully available? Reviewer #1: No Reviewer #2: No Please note that we have now made anonymised transcripts available in the Supporting information submitted with this revision. We have clarified that the transcripts have been checked to make sure they were anonymised and we have further redacted any potentially identifiable information. We have clarified that participants were made aware that anonymised interview data could be shared in future, and that they provided explicit consent for this. Reviewer #1: The investigators explored public attitudes towards drone-delivered AEDs for OHCA by conducting 14 semi-structured interviews with real-life OHCA bystanders. They identified 5 themes and devised interventions. 1. The sample size is small and it is unclear whether the subjects are representative of the general population. Nevertheless, the study provides clues on the complexity of the process. I suggest that the authors acknowledge the small sample size in the limitations section. We have added a section to the limitations “The sample size in this study is small and the participants might not be representative of the general population. It may have been that more motivated or confident bystanders were more likely to put themselves forward as participants. Certainly, a higher proportion of our participants reported CPR/AED training than the general UK population [42].” 2. The availability of AED doesn’t guarantee it being used. I would cite the Home use of AED trial (HAT), which did not improve the OHCA outcomes (DOI: 10.1056/NEJMoa0801651). One of the reasons for failure was insufficient use of the AEDs, despite resuscitation training, including AED, provided to the caregivers in the study. We agree that this is an important point. We have added the following text, including the above-mentioned reference: “Further, there is no guarantee that an AED will be used if available, which has been demonstrated in studies reporting the use of AEDs in both public [39] and home [40] settings.” 3. OHCA outcomes are better when the resuscitation response is integrated. Incorporation of drone-delivered AEDs require an integrated response from multiple stakeholders, including resuscitation services, drone operators, regulators, call handlers, CPR training providers. I would cite this paper (DOI: 10.1016/j.resuscitation.2016.10.029), tying the positive outcomes to integration of resuscitation response. Again, we agree that this is an important point. We have added the following text, including the suggested reference: “It is important that any drone-delivery system that is implemented at scale is fully integrated into the community and ambulance service response to out-of-hospital cardiac arrest, which will ensure the best chance of improved patient outcomes [45].” Reviewer #2: This is a well-conducted and timely qualitative study exploring bystanders’ perspectives on drone-delivered AEDs in OHCA. It makes an important contribution to understanding public acceptance and barriers to implementation of emerging prehospital technologies. Strengths: Clear use of theoretical frameworks (TDF, COM-B, Behaviour Change Wheel) to guide analysis and intervention development. Rich participant data, with well-chosen illustrative quotes. Identification of practical intervention areas (call-handler scripts, training, co-responder models) with real-world applicability. Transparent reporting following COREQ guidelines. Thank you for your feedback. Suggestions for minor revision: 1. Data availability statement: Clarify that anonymised transcripts are available on request because of participant confidentiality, as PLOS requires explicit justification for restrictions. We have now made anonymised transcripts available in the supplementary material submitted with this revision. 2. Methods – saturation: Expand on how thematic saturation was determined (e.g., what criteria were used at 14 interviews to conclude no new insights were emerging). Thank you, we have expanded the relevant section in the methods so that it now reads: “We conducted 14 eligible interviews, at which point we determined we had obtained a sufficiently thorough and nuanced understanding of the topics presented [36]. This was determined by the interviewer (CJB) after discussion with CMS, and was based not only on no new codes being identified but also on agreement that we had a rich understanding of the topic at hand that was unlikely to be added to by additional recruitment.” 3. Transferability of findings: Consider discussing how perceptions of drone technology may vary internationally and whether the UK-specific context (regulation, AED availability) limits generalisability. We have added a section in the limitations: “Further, these findings may not be fully applicable outside the UK. Whilst bystanders in simulation studies internationally generally respond positively to drones delivering AEDs [17,21-23], the delivery model in the UK may vary from those in other countries. Reasons for this may include differences in aviation regulations, existing AED availability and ambulance response times. This potentially limits the applicability of our findings to other countries.” 4. Limitations: Expand slightly on the possible impact of self-selection bias (motivated or more confident bystanders may have been overrepresented) and the exclusion of suspected fraudulent respondents. We have added the following limitations: “The sample size in this study is small and the participants might not be representative of the general population. It may have been that more motivated or confident bystanders were more likely to put themselves forward as participants. Certainly, a higher proportion of our participants reported CPR/AED training than the general UK population [42].” and (expanding our description of potential fraudulent responses): “Nonetheless, determining whether or not participants were genuine was subjective [35], and so some uncertainty must remain about around the validity of other participants whose data has been analysed. If we have erred in our decisions to exclude participants based on suspected fraud, this may impact the validity of our results.” 5. Language/clarity: Minor editorial corrections (e.g., sentence flow in Background and Discussion) will improve readability. We have reviewed the manuscript and made improvements where possible. Overall, this is an important and well-executed manuscript that will interest both emergency medicine and health policy audiences. I recommend acceptance after minor revisions. Thank you for your feedback. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0337082.r002
5 Nov 2025 Decision Letter - Nik Hisamuddin Nik Ab. Rahman, Editor Bystanders’ attitudes towards drone delivered Automated External Defibrillators for out-of-hospital cardiac arrest: a qualitative interview study. PONE-D-25-37331R1 Dear Dr. Smith, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Nik Hisamuddin Nik Ab. Rahman Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0337082.r003
Formally Accepted
Acceptance Letter - Nik Hisamuddin Nik Ab. Rahman, Editor PONE-D-25-37331R1 PLOS ONE Dear Dr. Smith, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Dr Nik Hisamuddin Nik Ab. Rahman Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0337082.r004

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