a b s t r a c t

Objective: The primary objective of this study is to better understand the preferences of the general pub- lic regarding cardiopulmonary resuscitation (CPR) education as it relates to both format and the time and place of delivery.

Methods: Survey data were collected from a convenience sample at large public gatherings in Baltimore, Maryland, between May 23, 2015, and February 11, 2017. The survey was a 23-item single-page instru- ment administered at fairs and festivals.

Results: A total of 516 surveys were available for analysis. Twenty-four percent of the total population reported being very confident in performing CPR (scoring 8 to 10 on a Likert scale). Thirty-two percent of respondents who had previously taken a CPR class reported being very confident in performing CPR. A stepwise decline in reported confidence in performing CPR was observed as the time from last CPR class increased. Among all respondents the most favored instruction style was an instructor-led class. Least favorable was a local learning station at an event. The most favored location for instruction were libraries, while community festivals were least favored.

Conclusion: Respondent preferences regarding the location and style of the training differed little between socioeconomic groups. Instructor-led instruction at local libraries was the most preferred option. CPR education offered at local learning stations during events and at community festivals were least favored among respondents. This study’s findings can be used to more effectively structure CPR out- reach and educational programs in an attempt to increase rates of bystander CPR.

(C) 2019

Introduction

Out-of-hospital cardiac arrest (OHCA) remains a persistent public health issue, affecting more than 356,000 people annually in the United States [1]. The provision of bystander cardiopul- monary resuscitation (CPR) has been consistently linked to improved rates of survival and neurological recovery [2-9]. Despite the overwhelming evidence that bystander CPR benefits victims of OHCA, its rates of performance vary greatly and remain low in most areas of the United States [2,4,10].

* Corresponding author at: Department of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

E-mail address: [email protected] (K.A. Fratta).

In an effort to increase the rate of bystander CPR, in 2008, the American Heart Association began to promote not-for-certification compression-only CPR training for laypersons. Compression-only CPR is a simple technique that is easily taught to laypeople and has been found to alleviate several barriers to the provision of bystander CPR including fear of infection and decreasing the time it takes to initiate compressions [11]. Many local and state Emergency medical services agencies and public health systems have embraced this public education concept and now offer compression-only or ”hands only” CPR training regularly.

Despite an increased emphasis on community CPR education, barriers to course delivery persist. A ”one size fits all model” may not address concerns related to geographic and student-specific social determinants. Many groups lag behind significantly in

https://doi.org/10.1016/j.ajem.2019.10.019

0735-6757/(C) 2019

bystander CPR rates, most notably the socioeconomically disadvantaged, the non-college educated, and non-English speakers [12].

A more nuanced understanding of CPR learner preferences is likely to improve educational outreach and give greater access to resources. Accordingly, an effective model of CPR education has the potential to promote increased delivery of bystander CPR and ideally affect overall survival rates after OHCA.

The primary purpose of our study is to describe the general public’s preferences regarding CPR education as it relates to course format, time of day, and location of course delivery. The second aim is to report and understand the preferences of groups that have traditionally been underrepresented in participating in bystander CPR courses.

Methods

We analyzed data collected at large public gatherings held in Baltimore, Maryland, between May 23, 2015, and February 11, 2017. The survey (Fig. 1) was a 23-item single-page instrument intended to be completed by people attending a large gathering such as a fair or festival. It was designed with the help of literacy experts to be comprehended at a third-grade reading level and included an informed consent statement. The survey tool was pilot tested in small group sessions where feedback was provided regarding the reliability and comprehension of the survey tool. The results of the pilot were only used in tool development and were not included in data analyses. All aspects of this study were conducted with approval from the Institutional Review Board in the Human Research Protection Office at the University of Maryland School of Medicine and from leaders of the Baltimore City Fire Department.

A convenience sample was recruited by approaching individu- als while they attended large public gatherings until an a priori defined response quota of 500 was obtained. Due to this style of survey collection it was not possible to calculate a response rate. Examples of these events include the African-American, and Latino-American, and Pride Festivals, Artscape, and HONfest as well as the BMore Healthy Expo, the MLK Day parade, Cupid’s Run, and the Women’s March on Baltimore. Large public gatherings such as those listed above were chosen as they allowed for rapid survey collection from a wide distribution of respondent demographics. Participation in our project was voluntary, and participants remained anonymous.

Data management and analysis

The paper survey data were entered manually into a Microsoft Access database (Seattle, WA). In order to stratify for socioeco- nomic status, we used the percent of people living in poverty in the respondents’ self-reported home zip codes and organized them into three a priori categories: low-poverty (0-9.9%), moderate- poverty (10-19.9%), and high-poverty (>=20%) areas. Poverty has previously been shown to limit health-seeking behaviors as well as provide an economic disincentive to learning health related skills such as CPR [13]. These categories allowed for us to compare socioeconomic status among respondents in our data set while limiting identifiable data elements.

A 10-point Likert scale was used to evaluate a respondent’s confidence with respect to the specific survey questions ranging between 1-not confident, 5-somewhat confident, and 10-very confident. Responses were dichotomized into ”very confident” (8 through 10) which were considered as ”yes” to the question and not very confident (7 and below) which were considered ”no”.

We used SPSS v. 25 (Armonk, NY) for statistical analysis. For difference in proportions and categorical data, we used the chi-squared test, and for continuous outcomes and categorical factors, we used analysis of variance (ANOVA).

Results

Five-hundred thirty-five surveys were collected, and 13 were excluded for incompleteness, leaving a total of 522 complete surveys. Six surveys were then excluded for indicating an age less than 14, leaving 516 surveys for analysis (Fig. 2).

The average age of respondents was 36.9 years (range, 14-84). Sixty-three percent of respondents were female. Fifty-four percent reported having a college education or higher. The racial/ethnic breakdown of respondents was 55% white, 36.6% black/African- American, and 8.3% other or mixed race; participants were able to select multiple race/ethnicity categories. About a third (34.1%) of respondents lived in low-poverty areas (0-9.9%), 39% in moderate-poverty areas (10-19.9%), and 26.9% in high-poverty areas (>=20%).

Sixty-eight percent of respondents reported having taken some form of CPR class; 83% of that group had completed a CPR class for certification. Twenty-four percent of all respondents reported being very confident in performing CPR (scoring 8, 9, or 10 on a 10-point Likert scale). Thirty-two percent of respondents who had previously taken a CPR class reported being very confident in performing CPR, whereas only 6.9% of those who had never taken a CPR class were very confident. Among those who had taken a CPR class, a stepwise decline was observed in reported confidence, ranging from 66.2% of those who had CPR training within the past year reporting very confident to 15.2% of those who had training more than 10 years ago (Fig. 3).

Participants reported a higher likelihood of performing CPR on family members (68.6%) than on strangers (44.8%) (p < 0.001). Eighty-six percent of respondents were unaware of the free com- munity CPR classes offered by the Baltimore City Fire Department. Respondents were asked what styles of CPR instruction they preferred and could select multiple options, if they selected more than 1 preference, they were prompted to choose which was their most preferred (Fig. 4). Among all respondents, instructor-led classes were most favorable at 76.2%, followed by educational video (40.3%) and one-on-one instruction (40.1%). Least favorable was a local learning station at an event or community festival, with 29.3% preferring this method. Of respondents reporting a home ZIP code from a high-poverty area, instructor-led instruction was most favorable at 80.3%. Similarly, least favorable was a local learning station at an event or in a store, with only 28.8% preferring that format. Among non-college-graduate respondents, instructor-led education was the most favorable at 73.1%. Likewise, a local learn-

ing station at an event or in a store was least favored at 26%.

Respondents were asked where they would prefer to complete their CPR training. Local libraries were most favored at 47.9%, followed by public schools (40.7%), a local fire department public training center (34.9%), a religious institution (30.6%), and commu- nity events (27.9%) (Fig. 5). Of respondents reporting a home ZIP code from a high-poverty area, local libraries were the most favored (47.7%). Least favored were community festivals and events (25.8%). Among non-college-graduate respondents, public schools were most favored (40.8%); community festivals and events garnered (28.3%). Least favored were religious institutions (22.4%).

Table 1 reports the times of day and days of the week that respondents preferred for CPR education. Saturday morning (32%), afternoon (33%), and early evening (31%) as well as Sunday afternoon (28%) and early evening (28%) were most preferred.

Fig. 1. The Baltimore City Fire Department wants to make sure its residents are trained about what to do in a medical emergency. As part of a community health project, we are teaching CPR to the community. CPR is a way of using chest compressions to pump someone’s heart if it suddenly stops beating. The following survey is part of a research study that will help us understand barriers to bystander CPR and help us learn what CPR classes are of the greatest interest to community. Completion of the survey is completely voluntary and indicates your consent to partake in our research study. Please contact Andrew Bouland at andrew. [email protected] with any questions or concerns. Thank you.

Fig. 1 (continued)

Discussion

Our study results describe social and logistical factors preferred by survey respondents and suggest strategies for improving

community outreach regarding CPR education. Prior studies demonstrated that increased community CPR training correlates with increased rates of survival after OHCA, including good neuro- logic outcome [14]. The majority of participants in our study had

Fig. 1 (continued)

70 66.2

32.4

22.6

19.4

15.2

6.9

60

50

40

Percent

30

20

10

0

< 1 year 1-2 years 3-5 years 6-10 years > 10 years No CPR class

Years since training

Fig. 3. Percentages of survey participants who were ”very confident” about performing CPR in relation to the time since they received training.

Fig. 2. CPR Educational Preference survey responses Strobe Diagram.

previous CPR training (n = 352, 68.2%), which is congruent with a reported national average of 65% of adults [15]. Respondents’ con- fidence in performing CPR eroded with time since their last CPR training. The step-wise decline in respondents’ reported confi- dence in providing CPR is in-line with reported layperson skill deterioration and further supports the need for CPR education organizers to consider the frequency of CPR related training [16]. Given that lack of confidence in CPR skills is a known barrier to bystander CPR, community CPR programs show promise as a

Instructor Video

One-on-one teaching Local learning station

9.2

16.8

15.2

58.9

Fig. 4. Study participants’ most preferred educational format (percentage).

Local libraries Public schools Local fire department Religious institution Community events

15.2

27.4

11.6

25.4

20.5

Fig. 5. Study participants’ most preferred location for CPR education (percentage).

means of facilitating skills practice for laypersons with previous CPR training as well as those with certification [17,18].

Instructor-led training was the preferred training methods across all socioeconomic subgroups. Learning stations at local events and in stores were the least favored. This is a relevant find- ing, because recent emphasis in community CPR training has focused on ”sidewalk” CPR sessions [19,20]. While these newer ”sidewalk” strategies conceivably allow for easier and more expe- dient training of laypeople it may be hampered if these strategies are not the preferred route and location of education. Future studies on the preferred locations and times will enhance our understanding of the most effective strategies for educating the public in the life-saving skill of CPR.

Although other investigators reported socioeconomic differ- ences in rates of bystander CPR and thus in survival rates following OHCA [12,21,22], our study showed that preferences for training styles and locations are comparable across a range of demographic groups. This important finding challenges the presumption that underserved urban populations need a different model of outreach for community CPR training. The people who participated in our survey favored Traditional methods of CPR community EDucation, possibly mirroring their previous CPR class experiences. The promotion of 30-minute compression-only CPR classes might increase community interest in acquiring life-saving skills.

Public schools were consistently in the middle of preferred loca- tion for CPR education and were most favored among non-college graduates. While this survey was primarily among adults it high- lights the importance of local public schools as sites of learning not only curricular materials but also public service. Several stud- ies have highlighted the efficacy of in school CPR education for school children and many U.S. states mandate such training by law [23-26]. Other studies have focused on the barriers to in- school CPR education. These include limited time for train-the- trainer style education for schoolteachers as well as limited knowledge of the skill. School teachers who underwent CPR educa- tion more than once were more willing to, in-turn, teach CPR to their students [27,28]. This is in-line with our findings that confi-

dence erodes with time from a learners last CPR class. As a method to increase the reach and efficacy of CPR education continuing CPR skills training should be a focus for learners and in particular schoolteachers tasked with training school children.

Similar public educational initiatives have been successful in teaching laypeople lifesaving medical skills such as first aid and Hemorrhage control. A common barrier to the provision of any of these lifesaving skills is the willingness to act. Studies have found the bystander effect and eroding confidence in these skills significantly decreases learners willingness to act especially when providing aid to strangers [29,30]. Curricular modifications specif- ically targeting pre-identified fears of providing first aid have been shown to increase learners willingness to act in an emergency [31,32]. Similar curricular modifications have been attempted in bystander CPR education, however they have not been proven effective in addressing learners’ medico-legal and infectious dis- ease fears [33]. More targeted curricular modifications may be needed to adequately address learner fears and foster an increased willingness to help.

Most of the participants in our study were unaware that free CPR education is provided by the local fire/EMS jurisdiction. These sessions should be promoted via social media or other forms of public information outreach in order to enhance the community’s awareness of them. Further research into methods for reaching out to underserved areas in particular is certainly warranted. Despite the lack of awareness of local CPR education efforts, the style and location preferences of the respondents, when combined with public outreach efforts, sheds light on ways to maximize attendance and learner satisfaction in a wide range of communities.

Limitations

Significant challenges are implicit in our study, as in all survey- based research. First, our surveys were collected in a single urban jurisdiction, so our findings might not be generalizable to other locations. Additionally, the technique of convenience sampling has the potential to introduce a degree of selection bias.. Also, given the open and informal nature of the community events, it was not possible to determine the total number of people who were approached, impeding our ability to calculate a survey com- pletion rate. The survey itself, while allowing respondents to pick multiple items for several questions, did not allow for an open response to any of the questions. Despite efforts to ensure reading comprehension by a broad range of participants, it is possible that the format may have been intimidating or less than accessible to some readers.

Conclusion

This study analyzed data collected from participants at large public gatherings in an inner-city environment to assess the

Table 1

Day and Hour Preferences for CPR Classes.

This table shows total responses per day/time slot. Each number indicates the percentage of participants who checked that box. Respondents were allowed to check more than one box. Box shading is: Black >= 30%, Grey 20-29%, White <= 19%.

public’s opinions and preferences regarding the logistics of CPR education. We found commonalities in both location preference and style preference among all socioeconomic groups represented by the participants in our survey. The most favored location among all respondents were local libraries. The least favored site for CPR education were local learning stations during events and commu- nity festivals. The most favored educational style was instructor- led CPR courses, while the least favored style was learning stations at events and community festivals. These findings may help inform programs, in similar areas, on strategies related to preferred course location and delivery model, in an effort to increase the reach of community CPR educational sessions.

Funding/Support

No funding or support to declare.

Conflict of Interest/Acknowledgment

Andrew J. Bouland serves as a board member for the Compress & Shock Foundation, a nationally recognized not-for-profit organi- zation that provides resources for free community CPR training. He has no financial interest in that organization. The manuscript was copyedited by Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine at the University of Maryland School of Medicine.

References

1. Writing Group Members, Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, et al. American Heart Association Statistics Committee, Stroke Statistics Subcommittee. Executive summary: heart disease and stroke statistics-2016 update: a report from the american heart association. Circulation 2016;133: 447-454.
2. Coons SJ, Guy MC. Performing bystander CPR for sudden cardiac arrest: Behavioral intentions among the general adult population in Arizona. Resuscitation 2009;80:334-40.
3. Urban J, Thode H, Stapleton E, Singer AJ. Current knowledge of and willingness to perform Hands-only CPR in laypersons. Resuscitation 2013;84:1574-8.
4. Lee MJ, Hwang SO, Cha KC, Cho GC, Yang HJ, Rho TH. Influence of nationwide policy on citizens’ awareness and willingness to perform bystander cardiopulmonary resuscitation. Resuscitation 2013;84:889-94.
5. Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen EF, et al. Association of national initiatives to improve Cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377-84.
6. Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out- of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63-81.
7. Kragholm K, Wissenberg M, Mortensen RN, Hansen SM, Malta Hansen C, Thorsteinsson K, et al. Bystander efforts and 1-year outcomes in out-of- hospital cardiac arrest. N Engl J Med. 2017;376:1737-47.
8. Stiell I, Nichol G, Wells G, De Maio V, Nesbitt L, Blackburn J. Spaite D, OPALS Study Group. health-related quality of life is better for cardiac arrest survivors who received citizen cardiopulmonary resuscitation. Circulation 2003;108:1939-44.
9. Park GJ, Song KJ, Shin SD, Lee KW, Ahn KO, Lee EJ, et al. Timely bystander CPR improves outcomes despite longer EMS times. Am J Emerg Med 2017.
10. Sipsma K, Stubbs BA, Plorde M. Training rates and willingness to perform CPR in King County, Washington: a community survey. Resuscitation 2011;82:564-7.
11. Sayre M, Berg RA, Cave D, Page R, Potts G, White R. Hands-only (compression- only) cardiopulmonary resuscitation: A call to action for bystander response to

    adults who experience out-of-hospital sudden cardiac arrest. Circulation 2008;117:2162-7.

    Sasson C, Meischke H, Abella BS, Berg RA, Bobrow BJ, Chan PS, et al. Increasing cardiopulmonary resuscitation provision in communities with low bystander cardiopulmonary resuscitation rates: A science advisory from the American heart association for healthcare providers, policymakers, public health departments, and community leaders. Circulation 2013;127:1342-50.

12. Banerjee A, Chaudhury S. Statistics without tears: Populations and samples. Ind Psychiatry J 2010;19:60-5.
13. Bouland AJ, Risko N, Lawner BJ, Seaman KG, Godar CM, Levy MJ. The price of a helping hand: modeling the outcomes and costs of bystander CPR. Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir 2015;19:524-34.
14. Blewer AL, Ibrahim SA, Leary M, Dutwin D, McNally B, Anderson ML, et al. Cardiopulmonary resuscitation training disparities in the United States. J Am Heart Assoc 2017;6.
15. Christenson J, Nafziger S, Compton S, Vijayaraghavan K, Slater B, Ledingham R, et al. The effect of time on CPR and automated external defibrillator skills in the Public access defibrillation Trial. Resuscitation 2007;74:52-62.
16. Lynch B, Einspruch EL. With or without an instructor, brief exposure to CPR training produces significant attitude change. Resuscitation 2010;81:568-75.
17. Dobbie F, MacKintosh AM, Clegg G, Stirzaker R, Bauld L. Attitudes towards bystander cardiopulmonary resuscitation: Results from a cross-sectional general population survey. PloS One 2018;13:e0193391.
18. Beskind DL, Stolz U, Thiede R, Hoyer R, Burns W, Brown J, et al. Viewing a brief chest-compression-only CPR video improves bystander CPR performance and responsiveness in high school students: A cluster randomized trial. Resuscitation 2016;104:28-33.
19. Benoit JL, Vogele J, Hart KW, Lindsell CJ, McMullan JT. Passive ultra-brief video training improves performance of compression-only cardiopulmonary resuscitation. Resuscitation 2017;115:116-9.
20. Mitchell MJ, Stubbs BA, Eisenberg MS. Socioeconomic status is associated with provision of bystander cardiopulmonary resuscitation. Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir 2009;13:478-86.
21. King R, Heisler M, Sayre MR, Colbert SH, Bond-Zielinski C, Rabe M, et al. Identification of factors integral to designing community-based CPR interventions for high-risk neighborhood residents. Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir 2015;19:308-12.
22. Watanabe K, Lopez-Colon D, Shuster JJ, Philip J. Efficacy and retention of Basic Life Support education including Automated External Defibrillator usage during a physical education period. Prev Med Rep 2017;5:263-7.
23. Brown LE, Lynes C, Carroll T, Halperin H. CPR Instruction in U.S. high schools: what is the state in the nation?. J Am Coll Cardiol 2017;70:2688-95.
24. Hsu S-C, Kuo C-W, Weng Y-M, Lin C-C, Chen J-C. The effectiveness of teaching chest compression first in a standardized public cardiopulmonary resuscitation training program. Med (Baltimore) [Internet] 2019;98.
25. Meissner TM, Kloppe C, Hanefeld C. Basic life support skills of high school students before and after cardiopulmonary resuscitation training: a longitudinal investigation. Scand J Trauma Resusc Emerg Med 2012;20:31.
26. Winkelman JL, Fischbach R, Spinello EF. Assessing CPR training: The willingness of teaching credential candidates to provide CPR in a school setting. Educ Health Abingdon Engl 2009;22:81.
27. Mpotos N, Vekeman E, Monsieurs K, Derese A, Valcke M. Knowledge and willingness to teach cardiopulmonary resuscitation: a survey amongst 4273 teachers. Resuscitation 2013;84:496-500.
28. Shotland RL, Heinold WD. Bystander response to arterial bleeding: helping skills, the decision-making process, and differentiating the helping response. J Pers Soc Psychol 1985;49:347-56.
29. Moon S, Ryoo HW, Ahn JY, Park JB, Lee DE, Kim JH, et al. A 5-year change of knowledge and willingness by sampled respondents to perform bystander cardiopulmonary resuscitation in a metropolitan city. PloS One 2019;14: e0211804.
30. Oliver E, Cooper J, McKinney D. Can first aid training encourage individuals’ propensity to act in an emergency situation? A pilot study. Emerg Med J EMJ 2014;31:518-20.
31. Ross EM, Redman TT, Mapp JG, Brown DJ, Tanaka K, Cooley CW, et al. Stop the bleed: the effect of hemorrhage control education on laypersons’ willingness to respond during a traumatic medical emergency. Prehospital Disaster Med 2018;33:127-32.
32. Fratta KA, Bouland AJ, Lawner BJ, Comer AC, Halliday MH, Levy MJ, et al. Barriers to bystander CPR: Evaluating socio-economic and cultural factors influencing students attending community CPR training. Am J Emerg Med 2018.