Abstract Body (Do not enter title and authors here): Introduction: Although previous research in high-income countries suggested that women are less likely to receive bystander CPR (BCPR) and tend to experience worse outcomes, there is a dearth of research on how they fare in lower-income, resource-limited countries compared to men in high-income countries.

Objectives: We aimed to elucidate the relationship between patient sex and country income on the receipt of bystander interventions and outcomes among OHCA patients from 13 income-diverse Asian and Middle Eastern countries. We hypothesized that female patients from lower-income countries will receive fewer bystander interventions and experience higher mortality rates than their male, high-income counterparts.

Methods: Our study employed a retrospective cohort design from the Pan-Asian Resuscitation Outcomes Study, 2009-2018. Country income classification was based on Gross National Income per capita. We excluded traumatic, pediatric, EMS-witnessed, healthcare setting, and missing arrest location cases. Using multivariable logistic regression, we assessed the odds of receiving public bystander CPR and AED, with patient sex, country income, and their interaction as predictors, controlling for age, witnessed status, year of OHCA, and time of emergency call. We assessed the odds of mortality with the same predictors, controlling for age, first rhythm, and emergency response time. Sex-income subgroups were predictors in subsequent analyses.

Results: Out of 207,450 cases, 54,483 met the inclusion criteria (2,749 in middle-income countries; 19,264, 35% females). Women from middle-income countries had lower adjusted odds of receiving public BCPR (AOR: 0.10, 95% CI: 0.05-0.17), as did men from middle-income countries (AOR: 0.18, 95% CI: 0.14-0.23),compared to men from high-income countries. Women across income-diverse countries had 23% lower adjusted odds of receiving bystander AED than men (AOR: 0.77, 95% CI: 0.62-0.96) and higher unadjusted odds of mortality than men (OR: 1.56, 95% CI: 1.44-1.68). Both female and male patients from middle-income countries had higher adjusted odds of mortality relative to those from high-income countries.

Conclusion: Women were less likely to receive bystander AED than men regardless of income country status. Women in middle-income countries were less likely to receive public BCPR than men in high-income countries. Female and male patients from middle-income countries were less likely to survive than their high-income counterparts.