|Year : 2021 | Volume
| Issue : 2 | Page : 121-131
A Survey of knowledge on and attitudes toward cardiopulmonary resuscitation and automated external defibrillators in China
Ming-Wei Wang1, Xin-Yan Fu1, Wen Wen1, Chun-Yi Wang1, Jie Ni1, Jing-Jie Jiang1, Min-Juan Wu1, Zhao Xu1, Yong-Ran Cheng2, Meng-Yun Zhou3, Lan Ye4, Zhan-Hui Feng5, Juan Chen1, Xing-Wei Zhang2
1 Hangzhou Institute of Cardiovascular Diseases, Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang Province, China
2 School of Public Health, Hangzhou Medical College, Hangzhou, Zhejiang Province, China
3 Department of Molecular & Cellular Physiology, Shinshu University School of Medicine, Japan
4 Department of Functional Laboratory, Basic Medical College, Guizhou Medical University, Guiyang, Guizhou Province, China
5 Department of Neurology, Affiliate Hospital of Guizhou Medical University, Guiyang, Guizhou Province, China
|Date of Submission||12-Dec-2020|
|Date of Acceptance||05-May-2021|
|Date of Web Publication||30-Jun-2021|
School of Public Health, Hangzhou Medical College, Hangzhou, Zhejiang Province
Source of Support: None, Conflict of Interest: None
Objectives: The aim of this study was to determine the current knowledge levels on cardiopulmonary resuscitation and automated external defibrillators of Chinese citizens. Methods: A face-to-face questionnaire survey on the knowledge of and attitudes toward the use of CPR and AEDs during an OHCA event was conducted in three high-traffic train stations in Hangzhou and Taizhou, China. The survey included questions on previous experience with CPR, recognition of cardiac arrest, CPR-related concerns, and AED knowledge. Results: A total of 6268 participants were surveyed about their knowledge of and attitudes toward the use of CPR and AEDs. A total of 5981 valid questionnaires, including 3008 from female respondents (50.2%) and 2973 from male respondents (49.8%), were retrieved. The participants were geographically distributed as follows: 18.5% from western China, 19.5% from central China, and 77.0% from eastern China. The educational level, regular residence, and sex of the respondents, as well as legislative policies, were relevant to the knowledge of and attitudes toward the use of CPR and AEDs for OHCA events. The results showed that men were more active than women in terms of CPR training and implementation, as well as had more knowledge and used AEDs more often. More people in eastern and central China had witnessed CPR performance, would pay for CPR training, and would be willing to perform CPR if there was a related legislative policy. Moreover, educational level was crucial to the knowledge of and attitudes toward the use of CPR and AEDs during OHCA events. Conclusions: Chinese citizens lack CPR and AED knowledge and training compared with people in developed countries. We recommend that the state should increase public awareness of CPR and AEDs in China. Mass education, policy implementation, specialized training, and legislative action should be carried out.
Keywords: Cardiopulmonary resuscitation; Defibrillators; Out-of-hospital cardiac arrest
|How to cite this article:|
Wang MW, Fu XY, Wen W, Wang CY, Ni J, Jiang JJ, Wu MJ, Xu Z, Cheng YR, Zhou MY, Ye L, Feng ZH, Chen J, Zhang XW. A Survey of knowledge on and attitudes toward cardiopulmonary resuscitation and automated external defibrillators in China. Cardiol Plus 2021;6:121-31
|How to cite this URL:|
Wang MW, Fu XY, Wen W, Wang CY, Ni J, Jiang JJ, Wu MJ, Xu Z, Cheng YR, Zhou MY, Ye L, Feng ZH, Chen J, Zhang XW. A Survey of knowledge on and attitudes toward cardiopulmonary resuscitation and automated external defibrillators in China. Cardiol Plus [serial online] 2021 [cited 2021 Oct 26];6:121-31. Available from: https://www.cardiologyplus.org/text.asp?2021/6/2/121/320317
Authors Ming.Wei Wang, Xin.Yan Fu and Wen Wen contributed
equally to this work.
| Introduction|| |
Out-of-hospital cardiac arrest (OHCA) is a major public health problem, and early implementation of cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators (AEDs) are crucial to survival. Approximately more than 230 million people suffer from cardiovascular disease annually worldwide, and about 550,000 people suffer from cardiovascular disease every year in China., The survival rate of people with OHCA in Europe is higher (average 23.3%) than that in China (<1%)., Such a high survival rate can be attributed to various improvements and public training measures implemented before the patient reaches the hospital.,,, In addition to China's lack of legal protection and traditional culture, the main reason for China's lower OHCA survival rate is the low rate of training in CPR and AED use for the general public. In 2013, 13.1 million people in the United States received professional CPR training. The overall rate of CPR training in China is less than 1% (33% in the United States and 40% in France), and skill retention training for CPR is also rare. Moreover, in China, the bystander CPR implementation rate for OHCA events is low (24.4%). However, in countries with the best emergency medical services, the implementation rates are as follows: 66% (The Netherlands), 68.8% (Victoria, Australia), 69% (King County, Seattle, Washington, USA), and 73% (Norway). Therefore, a topic of concern is how to improve the bystander CPR and AED implementation rates for OHCA events. Studies have shown that if the use of AEDs and CPR is gradually increased nationwide in China, the number of sudden cardiac deaths each year may be reduced by about 100,000. In China, few face-to-face surveys on OHCA events have collected data about the knowledge and willingness of bystanders to use CPR and AEDs. Therefore, in this study, we conducted a survey to determine the current knowledge levels on CPR and AEDs of Chinese citizens, with the goal of improving the survival rate of patients with OHCA in China. This represents a preliminary study to evaluate the feasibility of popularizing CPR and AED knowledge to improve the OHCA survival rate.
| Research Subjects and Methods|| |
The survey was conducted at three railway stations in Hangzhou and Taizhou, China. Hangzhou Railway Station, Hangzhou East Railway Station, and Taizhou Railway Station [Figure 1] were selected because they are the busiest transportation hubs in the two cities, and each station is therefore equipped with a public AED. The researchers considered that people familiar with CPR and AEDs are potential rescuers and they were, therefore, the surveyed population. Investigators surveyed people aged between 18 and 80 years at the railway station.
A cross-sectional survey of knowledge of and attitudes toward the use of CPR and AEDs for OHCA events was conducted among bystanders from March 01, 2018, to December 30, 2018, in Hangzhou and Taizhou, China. The adopted questionnaire format was used in previous studies,,,,,, but the present research included a set of new questions related to AED knowledge [Supplementary Material].
Ethical approval and consent to participate
The protocols of the current study were approved by the Research and Ethics Committee of the Affiliated Hospital of Hangzhou Normal University (Approval No. 2016ZB102). Information with regard to the objective of the study, the voluntary nature of participation, and the risk imposed due to involvement was presented in the information section of the survey. Informed consent forms were obtained from all participants. The confidentiality of the information was maintained, and the data were recorded anonymously throughout the study. This study was conducted in accordance with the Declaration of Helsinki.
Members of the research team stationed themselves at a high-traffic location at the station near the waiting area. Subjects who agreed to complete the survey and participate in the study signed the informed consent. Surveys were conducted on both working and nonworking days to increase the diversity of the survey research participants. People aged <18 and >80 years were excluded from the survey.
The research team created the questionnaire [Supplementary Material]. The participants were interviewed using face-to-face interview methods. All researchers initially received uniform training to ensure the consistency of data collection. If the individual verbally agreed to participate and met the age criteria, the researcher asked prewritten questions and recorded the individual's responses. The educational levels of the respondents were divided into five categories, namely illiterate, primary school, junior middle school, senior middle school, and bachelor's degree or above. The demographic data of each participant including basic information, such as age, sex, and occupation, were collected.
A total of 6268 individuals responded to the questionnaire, which included basic information and questions. Two hundred and eighty-seven invalid questionnaires (lack of information and incorrect data) were discarded, and 5981 valid questionnaires were finally included.
Descriptive statistics were used to describe the basic data of the surveyed population. Chi-square test and t-test were conducted to study the data stratified by variables (such as age and sex) to analyze P values with a 95% confidence interval. P < 0.05 was considered statistically significant. Logistic regression analysis was further used to screen important factors that affect CPR training. Statistical analysis was conducted using R statistical software (version 3.6.1; R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org.
| Results|| |
A total of 6,268 questionnaires were collected between March 1, 2018, to December 30, 2018, and the number of valid questionnaires was 5981 [Table 1]. Men and women accounted for 49.2% and 50.8% of the total number of respondents, respectively. Most of the respondents were between 18 and 60 years old, accounting for 91.7% of the total sample. With regard to the educational level of the respondents, 38.7% of the respondents held a bachelor's degree or above; 21.9%, a senior middle school diploma; 20.7%, a junior middle school diploma; and 13.6%, a primary school diploma and 5.1% were illiterate. The respondents were geographically distributed as follows: 18.5% from western China, 19.5% from central China, and 77.0% from eastern China. [Table 2] shows the distributions of the answers to the following questions: “Would you use AEDs on your family?” and “Would you use AEDs if you found someone experiencing sudden cardiac arrest?” People from eastern and central China provided more positive responses than those from western China. Moreover, more people in eastern and central China reported having witnessed CPR being performed and were willing to pay for CPR training. These results may be attributed to the higher economic and cultural levels and population densities of eastern and central China than those of western China. The respondents were also asked, “Do you believe you can save a person who is not breathing or does not have a heartbeat?” Respondents from different regions had varied answers. Moreover, [Table 3] reveals no statistically significant difference in the answers to the question, “Do you know how to use AEDs?” By contrast, the answers to the rest of the questions differed statistically significantly. Regardless of the educational level, the rate of understanding of the use of AEDs was low (13.4%–14.8%). Educational level was found to be crucial to the knowledge of and attitudes toward the use of CPR and AEDs during an OHCA event. The higher the educational level, the higher the willingness to use CPR and AEDs when an OHCA event occurs.
|Table 2: The results of the questionnaire on CPR and AEDs by interviewees|
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|Table 3: The results of the questionnaire on CPR and AEDs by different educational levels interviewees|
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[Table 4] shows that men were more active than women in the training and implementation of CPR and the use of AEDs. Univariate logistic regression analysis demonstrated that sex, educational level, the understanding of CPR, the willingness to pay for CPR training, self-confidence, and legislative support for CPR were the main influencing factors that affect the implementation of CPR among the survey participants (P < 0.05) [Figure 2].
|Table 4: The results of the questionnaire on CPR and AEDs by different genders interviewees|
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|Figure 2: Logistic regression univariate analysis of factors that affect cardiopulmonary resuscitation training.|
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| Discussion|| |
This survey summarized the experience and training of the Chinese public in the use of CPR and AEDs, as well as their attitudes toward their use. About 10.1% of people had received some form of CPR training in China, whereas 60% of people had undergone some CPR training in the UK. Among the survey respondents, the proportion of men (49.2%) and women (50.8%) was almost equal. According to reports, sex-based differences exist in the implementation of CPR,, but these differences were not found in the present study. However, the penetration rates of CPR and AEDs in different age groups were different. Most of the respondents were between 18 and 60 years old, accounting for 91.7% of the total sample. A previous research indicated that the overall CPR qualification rate of senior high school students in Shanghai is 7.7%. Moreover, people between 31 and 50 years of age and with a graduate degree or above are more knowledgeable about CPR. These findings are basically in line with the present survey results.
OHCA remains an important public health issue with a low survival rate in China (<1%), and measures must be taken to improve the survival rate. According to the American Heart Association (AHA), the first three steps of the survival chain include early access to emergency services, immediate CPR implementation, and early AED use. To the best of our knowledge, this survey is the first face-to-face questionnaire on the knowledge of and attitudes toward the use of CPR and AEDs during OHCA events in China. Since the economic and cultural levels and population densities of eastern and central China are higher than those of western China, more people in eastern and central China had witnessed CPR being performed and were more willing to pay for CPR training. Moreover, educational level was crucial to the implementation of CPR and the use of AEDs during OHCA events; the higher the educational level, the higher the willingness to conduct CPR and use AEDs during OHCA events. These findings are similar to the conclusions of a study conducted in the UK. These may be attributed to the higher the educational level, the stronger the understanding of and ability to learn how to conduct CPR and use AEDs, and therefore, the greater the willingness to implement CPR and use AEDs during OHCA events.
With regard to CPR training and implementation, men were more active than women, and the results of the present face-to-face questionnaire are consistent with those of previous online questionnaires. A study by Ge clearly indicated that China lacks public emergency response capabilities. According to an agreement between the Chinese government and the AHA, the partnership between the AHA and the China Social Relief Foundation established China's first public CPR training center in Beijing on October 12, 2016. It resulted in the training of millions of Chinese citizens in CPR. The Red Cross Society of China also conducts relevant AED and CPR training. For the public to be helpful in the face of an OHCA event, full use of these public training institutions must be made to continuously and repeatedly educate the public and enhance public awareness. The use of AEDs in public places can further increase the chance of electrocardioversion (ventricular fibrillation or pulseless ventricular tachycardia), thereby increasing the survival rate of patients with OHCA., Therefore, increasing the use of AEDs is essential to saving more lives. However, China's understanding of AEDs is low (13.4%–14.8%), and the training rate for AEDs is only 4.5%. By contrast, about 20% of 2084 adults from the UK reported having received AED training. The increase in the AED training rate must merit the full attention of the Chinese government and health management departments, as training can improve the survival rate of Chinese patients with OHCA. In addition, China should determine the knowledge of, attitudes toward, and use of CPR and AED training, such as the Heartstart course, Call Push Rescue program, and the international World Restart a Heart campaign of the British Heart Foundation in developed countries. The International Resuscitation Liaison Committee (ILCOR) launched the global “World Restart a Heart” initiative in 2018 with the slogan “All citizens in the world can save lives.” This initiative aims to increase the public knowledge and implementation rate of CPR by bystanders during OHCA events. While more than 675,000 nonmedical personnel are trained in CPR worldwide, China is unfortunately not included in ILCOR's global initiative. We urge the ILCOR to highlight the importance of China's CPR and AED use to make their slogan a reality. Moreover, to improve the public's understanding of CPR and AEDs, we recommend the implementation of mass education and specialized training, as well as the enactment of legislation to allow the use of CPR throughout China.
In contrast to the United States and European countries,,, China does not currently have legislation related to the use of CPR, and improving legal guarantees is particularly important to allow the use of CPR and AEDs. To actively promote the benefits of CPR and AEDs in China, various promotional materials including leaflets, posters, and electronic advertisements, as well as short video training, are acceptable forms of publicity.,, In short, in terms of CPR and AED knowledge, attitudes, and practices, China still has a long way to go to narrow its gap with developed countries.
| Conclusions|| |
Previous related questionnaires were mostly focused on CPR knowledge and attitudes but did not include AED knowledge and attitudes. Moreover, most were in the form of online questionnaires instead of face-to-face questionnaires. In this study, the knowledge of and attitudes toward the use of CPR and AEDs were analyzed according to the following: (1) educational level, (2) regional economic level, (3) sex differences, and (4) legislative support for CPR. The results indicated that to increase the implementation rates of CPR and AEDs during OHCA events in the Chinese population, definition of appropriate methods and interventions, such as improving CPR and AED knowledge, increasing CPR and AED knowledge training, and enacting legislation that allows for the use of CPR and AEDs during OHCA events, is necessary. When these comprehensive measures are implemented, the rates of CPR and AED use during OHCA events can possibly be increased in the Chinese population with the goal of improving the survival rate of Chinese patients with OHCA.
This research has the following limitations:
- The participants of the survey questionnaire were divided into those from eastern, central, and western China. Therefore, the survey data were limited because of fewer people in the central and western regions; thus, regional deviations might exist
- Although the questionnaire was a face-to-face survey, the environment might have affected the accuracy of the respondents' answers because the survey was conducted in busy and noisy train stations
- In this study, only railway stations were chosen as the research sites, which limited the screening of the population. Airports, universities, and other locations should be included in future studies to diversify the research population
- The original objective of this research was to attract attention at the national level to solve fundamentally the prominent problem of sudden cardiac death in the Chinese population.
Financial support and sponsorship
The presented study was supported by Hangzhou Science and Technology Bureau Fund (No. 20191203B96; No. 20191203B105); Zhejiang Traditional Chinese Medicine Science and Technology Plan (No. 2016ZB102); Clinical Research Fund Project of Zhejiang Medical Association (No. 2020ZYC-A13); Youth Fund of Zhejiang Academy of Medical Sciences (No. 2019Y009); Medical and Technology Project of Zhejiang Province (No. 2020362651, No. 2021KY890); and Hangzhou Health and Family Planning Technology Plan key projects (No. 2017ZD02).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]