Factors associated with death before EMS arrival among emergency medical services-attended self-directed violence cases in southern Iran: a cross-sectional study

Abstract

Abstract Background Self-directed violence (SDV) is an important public health concern, but evidence on factors associated with death before EMS arrival remains limited, particularly in low- and middle-income countries. This study examined factors associated with death before EMS arrival among EMS-attended SDV cases in southern Iran. Methods A cross-sectional study was conducted using EMS registry records of SDV cases attended in Fars Province, Iran, between March 2024 and March 2025. Data included age, sex, incident location, season, time of EMS call, mechanism of SDV, and EMS-recorded outcome. The primary outcome was death before EMS arrival, as recorded in the EMS registry. Associations were assessed using chi-square and Mann–Whitney U tests, followed by multivariable binary logistic regression. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were reported. Results Among 2,280 EMS-attended SDV cases, 124 (5.4%) were recorded as deaths before EMS arrival. The mean age was 30.1 ± 12.7 years, and 56.2% were male. Multivariable analysis included 2,145 complete cases. Increasing age was associated with higher odds of death before EMS arrival (AOR = 1.028, 95% CI: 1.011–1.046, p = 0.001). Compared with urban incident locations, rural incident locations had higher adjusted odds of death before EMS arrival (AOR = 2.075, 95% CI: 1.208–3.564, p = 0.008). Compared with evening calls, morning and afternoon calls were associated with higher odds of death before EMS arrival (AOR = 2.140, 95% CI: 1.063–4.308, p = 0.033 and AOR = 1.882, 95% CI: 1.006–3.520, p = 0.048, respectively). Compared with other methods, including unspecified mechanisms, poisoning was associated with lower odds of death before EMS arrival (AOR = 0.033, 95% CI: 0.008–0.137, p < 0.001), whereas hanging was associated with higher odds (AOR = 17.10, 95% CI: 10.101–28.951, p < 0.001). Sex and season were not independently associated with the outcome. Conclusions Among EMS-attended SDV cases, death before EMS arrival was associated with mechanism, age, incident location, and time of EMS call. The association with time of EMS call should be interpreted cautiously because the recorded time reflects EMS activation and does not indicate the timing of SDV onset or discovery; the observed pattern may partly reflect delayed recognition or discovery. The findings should also be interpreted in light of the observational design, restriction to EMS-attended cases, and limitations of routinely collected registry data.