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| Journal of the New Zealand Medical Association,
07-May-2004, Vol 117 No 1193
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Knowledge and attitudes towards cardiopulmonary resuscitation
in the community
Peter Larsen, Jake Pearson, and Duncan Galletly
The ability to deliver cardiopulmonary resuscitation, and
apply basic aspects of first aid, are important community skills that have been
shown to save lives.1–3
Survival from out-of-hospital cardiac arrest is dependant
upon the rapid institution of bystander cardiopulmonary resuscitation (CPR), and
the early arrival of advanced rescuers and equipment. Bystander CPR (comprising
airway opening, rescue breathing, and external chest compression; combined with
rapid call for ambulance response) improves survival rates from cardiac arrest
by 2–3 fold.1
Injuries kill more than 1100 New Zealanders each year, and
disable many more.2 Given that many trauma
victims die from the effects of haemorrhage and airway obstruction, it is
likely, therefore, that basic emergency care skills applied by bystanders (such
as control of external bleeding, positioning, and airway opening with cervical
spine control) could save at least some of these
lives.3
The importance of CPR and basic emergency care is recognised
in New Zealand by the inclusion of these subjects in the school curriculum
(albeit as an optional subject)4— and via
workplace first aid training by the Department of Occupational Health and
Safety.5
During 2002, more than 150,000 New Zealanders received
formal CPR and first aid training (6, 7). But despite these numbers, and the
associated cost, no research has explored the effectiveness of this training in
achieving high levels of resuscitation knowledge or skill within the New Zealand
community. Furthermore, no research has explored the attitudes of New Zealanders
towards resuscitation.
This present study was conducted to examine knowledge and
attitudes towards resuscitation in a New Zealand urban community.
MethodsOver a 2-week period (in June
2002) we conducted a telephone survey of 400 people selected from the 2002
Wellington telephone directory. Telephone numbers were selected as the
10th non-commercial entry on consecutive pages
of the directory. The first 400 consenting subjects over the age of 17 years
were included in the study. It is possible that this method of sampling may have
introduced some systematic form of bias. All calls were made between 6:00pm and
8:30pm.
After obtaining verbal informed consent, the telephone
questionnaire was delivered by asking a series of 16 questions from a computer
database program. These questions sought basic aspects of knowledge and
attitudes towards CPR/ first aid, as well as demographic information. The
subject’s responses were entered directly onto relevant fields of the
database. Repetition or clarification (of the question) was provided if the
subject felt it was necessary for them to understand. The series of questions
are listed in Table 1.
Table 1. Telephone survey questions
(1) Have you ever learnt how to do CPR?
If yes:
(2) How long is it since you
were last taught CPR?
(3) Where were you last
taught CPR?
(4) What do the letters 'CPR' stand for?
(5) The letters ABC are sometimes used as an aid for
remembering how to perform CPR. What do these letters stand for?
(6) CPR involves giving cycles of chest compressions
and expired air breaths. At what rate, per minute, would you give the chest
compressions for an adult subject?
(7) How many chest compressions, followed by how many
breaths, would you give in each cycle for an adult subject?
(8) Is a cardiac arrest the same thing as a heart
attack?
Do you think you would be willing to perform
mouth-to-mouth rescue breathing on:
(9) A member of your family?
(10) A stranger?
(11) You pull a 5-year-old child from a home swimming
pool. They do not respond, and are motionless. You realise you are alone. What
would you do first?
(12) Do you think simple first aid and CPR knowledge
should be compulsory in the Driver’s Licence written test?
(13) Do you think that you would like to know more
about CPR?
(14) What is your age?
18–25
26–35
36–45
46–65
66 or over
(15) What income bracket are you in?
less than $20,000
$20 000–$30,000
$30 000–$40,000
$40 000–$60,000
more than $60,000
(16) Which ethnic group do you identify most with?
NZ European
Maori
Cook Island Maori
Samoan
Nieuean
Tongan
Chinese
Indian
Other
As a simple index of the responder’s knowledge,
we calculated a total knowledge score from responses to knowledge questions 4,
5, 6, 7, 8, and 11, respectively. For each individual, we calculated a score
between 0 and 6 as the sum of correct responses from the six questions. P values
of less than 0.05 were considered statistically significant. No correction was
made for multiple comparisons. Statistical analysis was performed using
StatView® v5.0 software (SAS, Cary NC, USA.).
ResultsWe rang 526
numbers by telephone to obtain 400
eligible, consenting study subjects. Fifty-nine percent of those surveyed were
female; 10% were aged 18–25 years, 19% aged 26–35 years, 26% aged
36–45 years, 33% aged 46–65 years, and 12% aged 66 years and above.
Eighty-six percent of those surveyed identified themselves as NZ Europeans, 4%
as Maori, 2% as Chinese, 1% as Samoan, and 7% as other ethnic groups. Because of
the small numbers included within specific ethnic groups, further analysis
related to ethnicity was not conducted.
Prior learning of CPR296 subjects (74%) had been taught
CPR. Of these subjects, 12% had been taught during the previous 12 months, 14%
between 1–3 years previously, 11% between 3–5 years previously, and
63% over 5 years previously. Forty-four percent (of those persons taught) learnt
CPR through their workplace, 20% at school, 8% through sports groups, and 28%
elsewhere. There was no association between the proportion of subjects who had
learnt CPR and gender, or income. However older subjects were less likely to
have learnt CPR than younger subjects (p = 0.01, logistic regression).
Attitudes to CPR and first aid291 (73%) of surveyed subjects
wished to know more about resuscitation than they currently
did. The willingness to learn more
(about resuscitation) increased with age (p = 0.03, logistic regression). Desire
for further knowledge was not related to whether they had previously been taught
resuscitation, but those who wished to learn more had lower mean knowledge
scores than those who did not (mean [standard deviation] 1.73 [1.1] versus 2.5
[1.2], p = 0.03, unpaired t-test).
278 (70%) of surveyed subjects responded in the affirmative
when asked whether they thought that CPR and first aid knowledge should be a
compulsory component of the Driver’s Licence test. This opinion was not
related to age, gender, or income; or prior learning of CPR.
286 (72%) of surveyed subjects said they would be willing to
perform mouth-to-mouth expired-air-breathing on a member of their
family—with 252 (63%) willing to perform mouth-to-mouth on a stranger.
These responses did not differ by age, gender, or income.
Knowledge of CPRABC:
Only one subject knew that in the context of resuscitation, ABC stood for
airway, breathing, and circulation. One percent knew airway, 39% knew breathing,
and 27% knew circulation.
CPR: 162 (41%) of
surveyed subjects knew that ‘CPR’ stands for ‘cardiopulmonary
resuscitation’.
Chest compression
rate: Over half the subjects (55%) were unable to give an answer to this
question. Only 15 subjects (4%) gave a compression rate within the acceptable
range of 80 to 120 chest compressions per minute. The mean compression rate for
the 181 subjects who gave a numerical response was 45 per minute.
Compression / Ventilation
ratio: 225 (56%) of surveyed subjects were unable to provide an answer
for this question, and only 37 (9%) gave the correct (adult CPR)
compressions-to-ventilations
ratio—15(compressions):2(ventilations).
Initial treatment of an
unresponsive 5-year-old pulled from a swimming pool: Sixty-six percent of
subjects said that they would start CPR immediately (the correct response), 29%
said they would first phone 111, and 5% said they would go to get someone else
to help them.
Heart Attack / Cardiac
Arrest: 163 (40%) of subjects thought a heart attack was the same as a
cardiac arrest, with 177 (44%) correctly thinking the two were different.
Remaining subjects were unsure of the difference.
The knowledge score derived from the sum of these six
questions was correlated to other characteristics of the surveyed subjects
(Figure 1).
Figure 1. Mean knowledge scores of surveyed subjects (n
= 400)
 Error bars indicate standard deviation, for time since
last taught CPR, and age group in years. There was a significant relationship
between time since CPR was taught and knowledge score (p = 0.0001 logistic
regression). Knowledge score differed with age (p = 0.01, ANOVA), and was
greatest in those persons aged 26–35 years and 36–45
years.
There was a significant relationship between time (since CPR
was taught) and knowledge scores (p = 0.0001, logistic regression). There was no
gender difference in knowledge scores. There was a significant difference in
knowledge score with age (p = 0.01, ANOVA [Figure 1]—with those aged
26–35 and 36–45 having significantly greater knowledge than those
aged 18–25, 46–65, or over 65 years. Knowledge score differed with
income (p = 0.05 ANOVA, Figure 1), with the highest mean score for those in the
$40–$60,000 income bracket and the lowest scores in the less than $20,000,
and $20-$30,000 income brackets. With age and income in an analysis of
covariance, only age was significantly related to knowledge score (p = 0.01,
ANOVA).
DiscussionThis study examined some basic
aspects of knowledge and attitudes towards resuscitation in a New Zealand urban
community. The results suggest that, while the attitudes towards resuscitation
are generally positive, and a high proportion of the community have received
some level of resuscitation training, the level of resuscitation theoretical
knowledge is low.
The principle aim of resuscitation training is to ensure
that (in the event of a cardiac arrest), as many victims as possible receive
effective CPR. Studies have consistently found that bystander CPR increases
survival by 2–3 fold ,1 but rates of
bystander CPR internationally remain
low.8–10 In Auckland, Crone gave a
bystander CPR rate of 55% in 1991–1993,11
but there are anecdotal reports showing that (since that time) the rate of
bystander CPR has fallen to just under 50% (personal communication with St John,
Northern Region 2002, and Wellington Free Ambulance, 2001).
Overseas studies addressing a bystander’s willingness
to perform mouth-to-mouth ventilation on a stranger have found large
international variations. In Australia, 47% of people would perform rescue
breathing on a stranger,10 in the United States
15%,8 and in Japan only
2–3%.9
Although the likelihood of contracting HIV from rescue
breathing is extremely low (indeed there is no reported case), the American
study subjects cited fear of contraction of HIV as
the principal
concern. In contrast, in the Japanese study, despite the inevitable
outcome of untreated apnoea, fear of not being able to perform the skill
correctly was cited as the principle barrier.
Clearly, therefore, false perceptions relating to CPR skills
are an important factor that modifies a person’s willingness to provide an
important life saving skill. In this regard, the results from our current study
are encouraging—as 63% reported willingness to perform rescue breathing on
a stranger.
The perceived value of CPR / first aid knowledge by our
study subjects is evident in the observation that 70% answered affirmatively
when asked whether such knowledge should be a mandatory part of driver’s
licence testing. Given New Zealand’s high mortality from road trauma, it
is not unreasonable to expect that simple concepts of airway control, recovery
positioning, stopping bleeding by direct compression, as well as safe scene
management, could be included as part of the ‘road code’.
The present study indicates that some basic aspects of CPR
knowledge are poor. The most commonly used mnemonic to remind people of the
initial actions required in treating a collapsed subject is ‘ABC’
(Airway, Breathing, Circulation). Surprisingly, despite its perceived value by
the resuscitation training community, only one subject in the current study was
able to recall what ‘ABC’ stood for, and fewer than one quarter of
subjects recalled that B and C stood for breathing and circulation. When asked
practical questions regarding the performance of CPR, less than 10% of subjects
knew an acceptable compression rate, or the correct compression / ventilation
ratio.
It was surprising that despite the importance of
understanding the nature of a ‘heart attack’ and cardiac arrest,
fewer than half the subjects believed these to be different. We would argue that
if a basic concept such as this is so poorly understood, then, given the major
importance of myocardial infarction mortality, it is difficult to understand how
the general public is likely to fully appreciate the need for CPR, early access
to defibrillation, and early activation of the emergency medical systems with
myocardial infarction.
Studies have consistently shown poor retention of skills and
knowledge following resuscitation training,3,12
and consistent with this, knowledge scores were lower in those subjects trained
more than 12 months previously. However our results also suggest that
any previous training increased
knowledge relative to untrained subjects.
It could be argued that in real-life emergencies,
theoretical knowledge is less important that practical skill, and therefore the
simple knowledge score used in this study could not indicate the true
deterioration in a person’s CPR abilities. However studies have also
demonstrated that theoretical information (such as that asked in the current
study) tends to be better retained (in memory) than practical resuscitation
skills.12 It is therefore quite possible that,
had we been able to ask these people to physically perform CPR, performance
could have deteriorated to an even greater extent than theoretical knowledge
recall.
The majority of subjects indicated a desire to know more
about resuscitation that they currently did, particularly in the older age
groups. But despite this, the majority of subjects had not received any training
for more than 5 years. This implies that either the desire to learn is not
particularly strong in reality, or that the barriers to accessing information on
how to perform resuscitation are too great.
In conclusion, the attitudes of the community toward CPR
were positive, with an evident desire for greater resuscitation knowledge, and a
high willingness to perform CPR. Despite this, specific aspects of knowledge
relating to basic CPR was poor, thus indicating the limitation of present
educational strategies to increase CPR knowledge within the community.
Author information:
Peter D. Larsen, Lecturer, Section of Anaesthesia and Resuscitation; Jake
Pearson, Medical Student; Duncan C. Galletly, Associate Professor, Section of
Anaesthesia and Resuscitation, Wellington School of Medicine and Health
Sciences, Wellington
Acknowledgement:
This research was supported by a grant from the Wellington LifeSaver
Trust.
Correspondence:
Peter D. Larsen, Section of Anaesthesia and Resuscitation, Wellington School of
Medicine and Health Sciences, PO Box 7343, Wellington. Fax (04) 389 5318; email:
peter.larsen@wnmeds.ac.nz
References:
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