Influence of the Coronavirus Disease 2019 Pandemic and Bystander-victim Relationship on the Willingness of Laypeople and Health-care Providers to Perform Cardiopulmonary Resuscitation

Abstract

Introduction:

Bystander cardiopulmonary resuscitation (CPR) reduces mortality from out.of.hospital cardiac arrest. The willingness to perform CPR (W-CPR) is also critical. Uncertain effects of the coronavirus disease 2019 (COVID-19) pandemic on W-CPR were reported. Our objectives aim to examine W-CPR during the COVID-19 pandemic, including the influence of the bystander-victim relationship, bystander characteristics, and CPR background on the W-CPR of laypeople and healthcare providers (HCPs).

Methods:

A cross-sectional online survey was conducted between August 2020 and November 2020 among Thai laypeople and HCPs. A structured questionnaire was given to volunteers as an online survey. We recorded W-Conventional CPR (W-C-CPR), W-Compression.only CPR (W-CO-CPR), chest compression, automated external defibrillator (AED), mouth.to.mouth, face shield, and pocket mask ventilation on family members (FMs), acquaintances, and strangers during the study (pandemic) and in nonpandemic situation and analyzed.

Results:

We included 419 laypeople and 716 HCPs. During the pandemic, laypeople expressed less willingness in all interventions (P < 0.05) except W-CO-CPR in FMs and AED in FMs and acquaintances. HCPs were less willing to any interventions (P < 0.05). Laypeople showed comparable W-C-CPR and W-CO-CPR between FMs and acquaintances but less among strangers (P < 0.05). HCPs' W-CPR differed significantly depending on their relationship (P < 0.05), except W-CO-CPR between FMs and acquaintances. CPR self.efficacy, single marital status, CPR experience, and HCPs reported higher W-CO-CPR in FMs.

Conclusion:

Participants were less W-CPR during the COVID-19 pandemic on all recipients (laypeople: 2.8%–21.0%, HCPs: 7.6%–31.2%), except for laypeople with FMs. The recipient's relationship was more critical in W-C-CPR than in W-CO-CPR, especially in HCPs.

INTRODUCTION

Out-of-hospital cardiac arrest (OHCA) is a significant health problem in many Asian countries.[1] Bystander cardiopulmonary resuscitation (CPR) is a type of first aid that aims to manage cardiac and respiratory arrest until the victim can be sent to a medical facility.[2,3] Bystander CPR plays a vital role in improving survival to hospital discharge in OHCA victims.[4,5] There are two currently accepted bystander CPR techniques: conventional CPR (C-CPR) and chest compression-only CPR (CO-CPR).[2,3] C-CPR requires the knowledge and skills to perform an initial assessment, chest compression, ventilation, and automated external defibrillator (AED). C-CPR is recommended for health-care providers (HCPs) and laypeople trained and willing to give rescue breaths and chest compression.[2] CO-CPR is an alternative technique that does not require ventilation and is easier to learn and remember, thus increasing the likelihood of CPR.

Although knowledge and skills are essential factors in whether CPR is performed, the willingness of bystanders to initiate aid is also critical. Studies in various parts of Asia have found that anywhere from 10.5% to 79.0% of OHCA victims in the region receive CPR,[1,6] and willingness to perform CPR (W-CPR) ranges from 10.3% to 98.6%.[7,8,9,10,11,12] W-CPR is affected by various complex factors having to do with the bystander (experience, training, age, fear, self-efficacy, and physical fitness), technique (ventilation or nonventilation), the recipient (age, gender, and relationship), and the environment (location, country, safety, and infection risk).[8,10,11,12,13,14] Health-care professional is the one factor that increases W-CPR; however, it may affect by the coronavirus disease 2019 (COVID-19) pandemic. In addition, it seems likely that the possibility of airborne transmission of COVID-19 during ventilation and chest compression would negatively affect the willingness of bystanders to perform CPR.[15,16,17] Previous studies and a systematic review have yielded inconclusive data, especially in Asian countries.[16,17,18,19] In addition, considering the central role of the family and interpersonal relationships in many Asian cultures,[20,21] the degree of intimacy between bystanders and victims (such as family members [FMs], acquaintances, or strangers) may affect the decision to perform CPR. In our research, we conducted an anonymous online survey to study the influence of the COVID-19 pandemic and bystander-victim relationship on the W-CPR of laypeople and HCPs. We also studied the influence of bystander characteristics and CPR background on W-CPR during the COVID-19 pandemic.

METHODS

Study design

This prospective descriptive study was based on a cross-sectional survey conducted in Thailand between August 31, 2020, and November 30, 2020. We obtained Institute Review Board approval before commencing the study (HE631328). The authors designed and developed a structured questionnaire based on those described in the previous studies,[9,10,11] with the content adjusted for use in a Thai context. We had three experts in the content area test the content validity (content validity index: 0.95). We then conducted a pilot study with 30 participants to determine the reliability of the questionnaire, which was then modified based on the results. The final questionnaire showed acceptable reliability, with a Cronbach's alpha coefficient of 0.86 (95% confidence interval [CI]: 0.78–0.92). This study is also reported following the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

Questionnaire

Participants filled out an electronic consent form before taking the questionnaire. The questionnaire included participant characteristics and willingness to perform bystander CPR [Additional File 1 ^{(982.1KB, pdf)} ]. The participant characteristics consisted of 10 questions to determine gender, age, marital status, education level, work status, CPR background (heard of CPR, CPR training, experience in performing CPR, CPR self-efficacy [by self-judgment]), and whether the respondent was a layperson or HCPs (such as a doctor, dentist, pharmacist, nurse, medical technician, physical therapist, or physician assistant). Willingness to perform bystander CPR was assessed for seven interventions: C-CPR (whether it be mouth-to-mouth, face shield, or pocket mask), CO-CPR, chest compression, use of an AED, mouth-to-mouth ventilation, mouth-to-face shield ventilation, and mouth-to-pocket mask ventilation. Participants were asked to indicate their willingness to perform each technique on FMs (close relatives of the participant and extended family), acquaintances (someone the participant knows personally or socially), and strangers. The situation was as follows: “Imagine you came across an unconscious person in a restaurant during the current pandemic. Would you perform CPR? How about in a time when there is no pandemic?” The pandemic period definition was a study period (0–22 new COVID-19 infection cases per day). Possible answers were “yes,” “no,” and “not sure.” A “yes” answer was classified as willing to perform CPR and “no” or “not sure” as unwilling. All questions had to be answered. However, we did not record names, E-mail addresses, or phone numbers to maintain anonymity. The questionnaire included CPR information, such as pictures and descriptions, to assist participants in deciding and reducing recall bias. The questionnaire took approximately 15 min to complete.

Data collection

Volunteers were recruited using an online survey (Google Forms, Google Inc.) distributed through official E-mail contact lists of Khon Kaen University, the public health offices of each province in Thailand, and the author's E-mail contact lists. Participants could share the link with their network through E-mail. The first page of the survey described the purpose of the study and information about participation (including the right to withdraw) and was permitted to complete the questionnaire once. A questionnaire could only be accessed after the participant agreed to participate. We sent out a reminder to our contacts to encourage them to complete our survey.

Statistical analysis

Data analysis was performed using SPSS Statistics for Windows version 26.0 (IBM Corporation, Armonk, NY, USA). Subgroup analysis was performed for laypeople and HCPs. We used descriptive statistics to describe participant characteristics. Categorical data were summarized as percentage and frequency, and continuous data as mean and standard deviation (SD). We calculated proportions based on the number of participants with nonmissing data. We compared the influence of the pandemic using the Chi-square test and calculated the odds ratio (OR) with a 95% CI. We compared W-CPR on FMs, acquaintances, and strangers using two proportion Z-tests and calculated a difference in proportion with a 95% CI or P value, as appropriate. All associated factors were considered dichotomous variables except for age, education level, and work status, which were considered polytomous variables. Univariable analysis was used to assess the associations between pairs of categorical variables (Chi-square test or Fisher's exact test, as appropriate). Multivariate analysis was performed through logistic regression by an enter method on all associated factors with P < 0.2. Results were reported as ORs with 95% CI. Each group's estimated required sample size was 400 participants calculated based on a 95% CI, type I error of 0.05, an estimated prevalence of willingness to perform CO-CPR based on previous studies, absolute precision of 0.10, and power of 80%.[16,17,18,19]

RESULTS

Because we could not accurately determine the total number of people who received a link to the questionnaire, it was impossible to calculate the response rate. However, we included 419 laypeople and 716 HCPs. There were no missing data. Laypeople were 65.3% female, with a mean (SD) age of 37.3 (14.5) years. The HCPs group was 75.1% female with a mean (SD) age of 39.9 (11.4) years. Participant characteristics are shown in Table 1.

Table 1.

Participant characteristics

Variables	Laypeople group (n=419), n (%)	HCPs group (n=716), n (%)
Female	274 (65.3)	538 (75.1)
Age (years), mean (SD)	37.3 (14.5)	39.9 (11.4)
Married status	207 (49.4)	272 (38.0)
Education level
Primary education or under	4 (1.0)	0
Secondary education	83 (19.7)	15 (2.1)
Bachelor’s degree	180 (43.0)	467 (65.2)
Master’s degree or higher	135 (32.2)	213 (29.8)
Not specified	17 (4.1)	21 (2.9)
Work status
Full time	241 (57.5)	616 (86.0)
Part-time	24 (5.7)	23 (3.2)
Retired	20 (4.8)	19 (2.7)
Unemployed	21 (5.0)	4 (0.6)
Student	60 (14.3)	28 (3.8)
Not specified	53 (12.7)	26 (3.6)
Heard of CPR	274 (65.4)	708 (98.9)
CPR training	191 (45.6)	707 (98.7)
Experience performing CPR	51 (12.2)	541 (75.6)
CPR self-efficacy	57 (13.6)	521 (72.8)

CPR: Cardiopulmonary resuscitation, SD: Standard deviation, HCPs: Health-care providers

Influence of coronavirus disease 2019 pandemic

As shown in Table 2, lay participants were less willing to perform C-CPR regardless of their relationship during the COVID-19 pandemic than during a nonpandemic period. Laypeople were also less willing to perform CO-CPR on acquaintances (OR: 0.74 [0.57–0.97]) and strangers (OR: 0.62 [0.46–0.81]), but this was not the case for FMs. In nearly all cases, participants were less willing to perform chest compression, mouth-to-mouth, mouth-to-face shield, or mouth-to-pocket mask ventilation during the pandemic. However, lay participants' willingness to perform AED on FMs and acquaintances did not differ but showed less willingness in strangers (OR: 0.71 [0.54–0.94]). Health-care professionals were less willing to perform C-CPR and CO-CPR during the pandemic, regardless of their relationship with the victim. In addition, participants were less willing to perform chest compression, AED, mouth-to-mouth, mouth-to-face shield, or mouth-to-pocket mask ventilation during the pandemic in nearly all cases.

Table 2.

Influence of the coronavirus disease 2019 pandemic on willingness to perform cardiopulmonary resuscitation

	Laypeople group (n=419)			HCPs group (n=716)
	Nonpandemic, n (%)	Pandemic, n (%)	OR (95% CI)	Nonpandemic, n (%)	Pandemic, n (%)	OR (95% CI)
Conventional CPR
FMs	180 (43.0)	92 (22.0)	0.37 (0.28–0.51)*	464 (64.8)	251 (35.1)	0.29 (0.24–0.36)*
Acquaintances	166 (39.6)	78 (18.6)	0.35 (0.25–0.48)*	388 (54.2)	165 (23.0)	0.25 (0.20–0.32)*
Strangers	118 (28.2)	57 (13.6)	0.40 (0.28–0.57)*	283 (39.5)	124 (17.3)	0.32 (0.25–0.41)*
Chest compression-only CPR
FMs	205 (48.9)	193 (46.1)	0.89 (0.68–1.17)	645 (90.1)	591 (82.5)	0.52 (0.38–0.71)*
Acquaintances	213 (50.8)	182 (43.4)	0.74 (0.57–0.97)*	640 (89.4)	561 (78.4)	0.43 (0.32–0.58)*
Strangers	186 (44.4)	138 (32.9)	0.62 (0.46–0.81)*	615 (85.9)	517 (72.2)	0.43 (0.33–0.56)*
Chest compression
FMs	237 (56.6)	177 (42.2)	0.56 (0.43–0.74)*	669 (93.4)	587 (82.0)	0.32 (0.22–0.45)*
Acquaintances	237 (56.6)	176 (42.0)	0.56 (0.42–0.73)*	668 (93.3)	581 (81.1)	0.31 (0.22–0.44)*
Strangers	216 (51.6)	150 (35.8)	0.52 (0.40–0.69)*	615 (85.9)	506 (70.7)	0.40 (0.30–0.52)*
AED
FMs	222 (53.0)	215 (51.3)	0.94 (0.71–1.23)	645 (90.1)	591 (82.5)	0.52 (0.38–0.71)*
Acquaintances	222 (53.0)	201 (48.0)	0.82 (0.62–1.07)	645 (90.1)	591 (82.5)	0.52 (0.38–0.71)*
Strangers	210 (50.1)	175 (41.8)	0.71 (0.54–0.94)*	628 (87.7)	563 (78.6)	0.52 (0.39–0.69)*
Mouth-to-mouth ventilation
FMs	161 (38.4)	50 (11.9)	0.22 (0.15–0.31)*	380 (53.1)	160 (22.3)	0.25 (0.20–0.32)*
Acquaintances	140 (33.4)	34 (8.1)	0.18 (0.12–0.26)*	268 (37.4)	60 (8.4)	0.15 (0.11–0.21)*
Strangers	99 (23.6)	25 (6.0)	0.21 (0.13–0.33)*	177 (24.7)	33 (4.6)	0.15 (0.10–0.22)*
Mouth-to-face shield ventilation
FMs	150 (35.8)	95 (22.7)	0.53 (0.39–0.71)*	404 (56.4)	215 (30.0)	0.33 (0.27–0.41)*
Acquaintances	134 (32.0)	72 (17.2)	0.44 (0.32–0.61)*	327 (45.7)	106 (14.8)	0.21 (0.16–0.27)*
Strangers	91 (21.7)	48 (11.5)	0.47 (0.32–0.68)*	220 (30.7)	67 (9.4)	0.23 (0.17–0.31)*
Mouth-to-pocket mask ventilation
FMs	220 (52.5)	168 (40.1)	0.61 (0.46–0.80)*	540 (75.4)	316 (44.1)	0.26 (0.21–0.32)*
Acquaintances	191 (45.6)	127 (30.3)	0.52 (0.39–0.69)*	469 (65.5)	193 (27.0)	0.19 (0.16–0.24)*
Strangers	136 (32.5)	89 (21.2)	0.56 (0.41–0.77)*	347 (47.8)	129 (18.0)	0.23 (0.18–0.30)*

*Statistically significant (P<0.05). CPR: Cardiopulmonary resuscitation, OR: Odds ratio, CI: Confidence interval, HCPs: Health-care providers, FMs: Family members, AED: Automated external defibrillator

Influence of interpersonal relationships

Table 3 compares participants' W-CPR during the pandemic to their relationship with the victim. There was no difference in laypeople's W-CPR (C-CPR and CO-CPR) between FMs and acquaintances. However, HCPs showed a difference in willingness to perform C-CPR and CO-CPR between any relationships except the willingness to perform CO-CPR between FMs and acquaintances. All participants were more willing to perform CPR on FMs and acquaintances than strangers.

Table 3.

Influence of interpersonal relationships on willingness to perform cardiopulmonary resuscitation during the coronavirus disease 2019 pandemic

	Difference in proportions (95% CI)
	Laypeople group (n=419)	HCPs group (n=716)
Conventional CPR
Between FMs and acquaintance	3.4 (−2.1–8.8)	12.1 (7.4–16.8)*
Between FMs and stranger	8.2 (3.0–13.4)*	17.8 (13.2–22.3)*
Between acquaintance and stranger	5.0 (0.2–10.0)*	5.7 (1.5–9.9)*
Chest compression-only CPR
Between FMs and acquaintance	2.7 (−4.0–9.4)	4.1 (−0.1–8.2)
Between FMs and stranger	10.5 (3.9–17.1)*	10.3 (6.0–14.6)*
Between acquaintance and stranger	10.5 (3.9–17.1)*	6.2 (1.7–10.7)*

*Statistically significant (P<0.05). CPR: Cardiopulmonary resuscitation, CI: Confidence interval, HCPs: Healthcare providers, FMs: Family members

Willingness to perform cardiopulmonary resuscitation versus participant characteristics and cardiopulmonary resuscitation background

As shown in Table 4, HCPs and CPR self-efficacy were more likely to perform CO-CPR regardless of the relationship. At the same time, single marital status was related to a higher willingness to perform CO-CPR on FMs and acquaintances. CPR experience was associated with a higher willingness to perform CO-CPR on FMs. At the same time, we did not find any factors related to a higher willingness to perform C-CPR.

Table 4.

Factors associated with willingness to perform compression-only cardiopulmonary resuscitation during the coronavirus disease 2019 pandemic (only significant factors were reported)

Factors	OR (95% CI)
	FMs		Acquaintances		Strangers
	Univariate	Multivariate	Univariate	Multivariate	Univariate	Multivariate
Single marital status	1.32 (1.02–1.71)	1.91 (1.30–2.81)	1.40 (1.09–1.80)	1.88 (1.32–2.70)	NS	NS
CPR experience	3.26 (2.50–4.25)	1.67 (1.01–2.78)	3.04 (2.36–3.93)	NS	3.50 (2.74–4.49)	NS
HCP	5.34 (4.07–7.00)	2.00 (1.24–3.23)	4.57 (3.51–5.93)	1.73 (1.10–2.73)	5.16 (3.97–6.69)	1.63 (1.05–2.52)
CPR self-efficacy	5.07 (3.82–6.74)	1.96 (1.24–3.09)	4.39 (3.36–5.73)	1.81 (1.18–2.77)	4.59 (3.56–5.93)	1.73 (1.17–2.55)

HCP: Health-care provider, CPR: Cardiopulmonary resuscitation, OR: Odds ratio, CI: Confidence interval, NS: Not statistically significant, FMs: Family members

DISCUSSION

We found that participants were less willing to perform CPR to any interventions during the COVID-19 pandemic [Table 2], except for CO-CPR and using an AED in cases where the bystander is a layperson and the victim is an FM. Laypeople's willingness to use AED for acquaintances also was comparable. The relationship between bystander and victim significantly affected the W-CPR, especially with strangers. CPR self-efficacy, single marital status, and HCPs were associated with a higher willingness to perform CO-CPR.

Our study population represents urban residents who can participate in an online survey. Most were female, had a bachelor's degree, and worked full-time. The mean age was about 40 years. We found that 65.4% of laypeople had heard of CPR, compared to about 90% in studies in other Asian countries.[8,9] This suggests the need for better CPR recognition in Thailand. However, 45.6% of laypeople who had taken a CPR course were comparable with previous studies.[8,9] Two-thirds of HCPs and 13.6% of laypeople expressed CPR self-efficacy, which may affect their W-CPR. These results show that the W-CPR in Thailand has reduced during the pandemic, although our study occurred during a period in which Thailand had few COVID cases (0–22 new cases/day). However, the lack of an available vaccine may have contributed to participants' reluctance. By contrast, a previous systematic review could not provide a firm conclusion as to the effect of COVID-19 on bystanders' W-CPR. While studies from Western countries have shown lower rates of bystander CPR, results from Asian countries have been inconsistent.[15,16,17,18] The severity of the situation might affect willingness, but further study is required to determine whether this is the case.

We found that the pandemic significantly impacted participants' W-C-CPR (50% reduction) than CO-CPR. Similar decreases were seen in the willingness to perform mouth-to-mouth, mouth-to-face mask, or mouth-to-pocket mask ventilation. The fact that ventilation is an aerosol-generating procedure (AGP) might cause participants (especially HCPs) to be wary of the risk of transmission. Similarly, the lack of clarity about whether chest compressions and defibrillation are AGPs may have affected participants' willingness to perform these procedures.[22]

We also found that the participant's relationship with the victim affected their W-CPR. While laypeople were equally willing to perform CO-CPR on FMs, this was not true of HCPs, possibly out of fear of transmission. This suggests that the relationship with the victim may be a more significant factor for HCPs than laypeople. Participants in both groups were least likely to perform CPR on strangers, consistent with other studies.[16,17,18,19] Previous study also reported that the critical factor in willingness was fear of contacting and transmitting COVID-19.[23] Other factors include fear of isolation, no effective COVID-19 treatment and vaccines, low survival rate victim, and no personal protective equipment.[23] Overall W-CPR (pandemic and nonpandemic) in our study was lower than in previous studies.[7,8,9,10] Our study's overall W-CPR decreased by about 2.8%–21.0% among laypeople. However, it decreased by about 7.6%–31.2% in HCPs, which was higher than in previous studies (1.6%–19.5%).[16,17,18,19] This may have been partly due to the low percentage of CPR self-efficacy in lay participants. A cultural fear of making mistakes may have been another factor, particularly the laws of a country and citizens' awareness of them. In some Western countries, it is relatively well-known that Good Samaritan laws protect bystanders who perform CPR. By contrast, a previous study in Hong Kong showed that only 12.1% of the population knew the concept of a Good Samaritan Law.[24] Thailand's Good Samaritan law has been in effect since 2015.

In our study, HCPs and CPR self-efficacy were associated with willingness to perform CO-CPR (but not C-CPR). Being single was also associated with higher willingness, but only with FMs and acquaintances. However, our sample size was insufficient to determine a conclusive association. We found no correlation between gender, education, or experience with CPR training, as have previous studies.[8,11,13,14] Strategies to increase the rate of bystander CPR should focus on how people view interpersonal relationships, culture, and differences between HCPs and laypeople. Adopting CPR techniques that limit COVID-19 transmission might be a way to increase the willingness of bystanders to perform CPR.

Our results showed that 70%–90% of participants would refuse to perform C-CPR during the pandemic, and 60%–95% would refuse to perform ventilation, despite our having included a description of the ventilation technique and its benefits in the survey. In HCPs, 72.2%–82.5% were willing to perform CO-CPR compared to 17.3%–35.1% for C-CPR. Strategies to increase the rate of bystander CPR should focus on how people view interpersonal relationships, culture, and differences between HCPs and laypeople. Adopting CPR techniques that limit COVID-19 transmission might be a way to increase the willingness of bystanders to perform CPR.

One limitation of this study was selection bias, as those interested in CPR or with CPR knowledge was more likely to participate in the survey, thus affecting the results. In addition, W-CPR is a surrogate outcome that may not accurately reflect behavior in real-life situations. However, measuring the prevalence of actual CPR performance during the pandemic would have been prohibitively complex, so we selected the willingness to perform bystander CPR as a representation. Furthermore, although a high percentage of the Thai population has internet access, our survey was conducted online. Our participants were likely disproportionately urban-dwelling and in the middle-to-upper socioeconomic class. Despite these limitations, our study provided data regarding the impact of the pandemic and the relationship between bystanders and the victim on W-CPR.

CONCLUSION

W-CPR during the COVID-19 pandemic is less than in nonpandemic, except for CO-CPR, in cases where the bystander is a layperson and the victim is a FM. The percentage of reduction is between 2.8% and 21.0% among laypeople and 7.6%–31.2% among HCPs. The relationship between bystander and victim significantly affected the W-CPR, especially with strangers. CPR self-efficacy, single marital status, and HCPs were associated with a higher willingness to perform CO-CPR during the COVID-19 pandemic.

Author's contributions

BS, MT, BPI, and BPO conceived and designed the study. BS, MT, BPI, and BPO developed the study protocol. BS, MT, and BPO designed and tested the study instrument. BS, MT, BPI, and BPO supervised data collection. BS, MT, and BPO analyzed the data. BS, MT, BPI, and BPO prepared and approved the manuscript. All authors read and approved the final manuscript.

Research quality and ethics statement

This study was approved by Khon Kaen University's human research ethics committee, Thailand (HE631328). The authors followed applicable EQUATOR Network (STROBE guidelines) during the conduct of this research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.