Public-Access Defibrillation in Megacities: Structural Barriers and Systemic Opportunities in Shanghai, China

Despite nationwide efforts to expand public-access defibrillation (PAD) in China, the use of automated external defibrillators (AEDs) remains extremely low. Although spatial disparities in AED deployment have been widely reported, less is known about the structural, procedural, and behavioral factors that hinder effective use in real-world emergencies. This study explored multilevel barriers and opportunities within Shanghai's PAD system.

Guided by the Social Ecological Model, we conducted in-depth semi-structured interviews with 42 participants involved in AED financing, deployment, management, maintenance, training, digital platform development, and emergency response. Interviews were conducted between December 2024 and June 2025, with data transcription, checking, and preliminary analysis continuing until July 2025. Data were analyzed using inductive and deductive thematic analysis. Themes were organized across system, organizational, community, and individual levels.

Shanghai's PAD system is shaped by interacting barriers across multiple levels. At the individual level, limited emergency knowledge, fear of causing harm, and uncertainty about legal protection reduced bystanders' willingness to act. At the organizational and system levels, fragmented governance, inconsistent maintenance standards, restricted venue access, non-standard signage, and disconnected digital platforms limited AED visibility, accessibility, and timely activation. At the same time, several opportunities emerged. High-willingness population groups could be targeted through scenario-based, recurrent training. Data-informed AED siting and hybrid fixed-plus-mobile deployment models using taxis or delivery riders may help reduce spatial inequities. Participants also highlighted the need for a centralized, government-led AED information platform linked to emergency dispatch and device management.

AED installation alone is insufficient to deliver effective PAD. In Shanghai, PAD performance is constrained less by device availability itself than by fragmented governance, weak system integration, and persistent behavioral barriers. Strengthening legal protection, improving cross-sector coordination, integrating AED information with dispatch systems, and promoting activation-oriented public training may help translate AED availability into lifesaving action.