A national survey of prevalence of cardiopulmonary resuscitation training and knowledge of the emergency number in Ireland

A national survey of prevalence of cardiopulmonary resuscitation training and knowledge of the emergency number in Ireland
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  Resuscitation 80 (2009) 1039–1042 Contents lists available at ScienceDirect Resuscitation  journal homepage: Simulation and education A national survey of prevalence of cardiopulmonary resuscitation training andknowledge of the emergency number in Ireland  Siobhan Jennings a , ∗ , Tom O. Hara b , Brendan Cavanagh c , Kathleen Bennett b a Department of Public Health, Health Service Executive, Dr. Steevens Hospital, Dublin 8, Ireland b Department of Pharmacology & Therapeutics, Trinity Centre for Health Sciences, St James’s Hospital, Dublin 8, Ireland c Health Service Executive South, Aras Slainte, Wilton Rd., Cork, Ireland a r t i c l e i n f o  Article history: Received 12 February 2009Received in revised form 18 May 2009Accepted 23 May 2009 Keywords: Cardiopulmonary resuscitationEmergency numberIrelandSurveyKnowledge a b s t r a c t  Aim:  The aim of this survey was to establish prevalence of cardiopulmonary resuscitation (CPR) trainingwithinthelast5yearsandreasonspreventingtrainingandinitiationofCPRinIrelandaswellasawarenessof the emergency numbers. Methods:  An in-home omnibus survey was undertaken in 2008 with quota sampling reflecting the age,gender, social class and geography of Ireland. Results:  Of the 974 respondents, 23.5% had undergone CPR training in the previous 5 years with lowersocial class and age 65 years and older significantly less likely to be trained. The workplace was both amajorsourceofawarenessaswellastrainingforthosetrained.Intheuntrainedgrouplackofawarenessof theneedforCPRtrainingwasthemostsignificantreasonfornon-training.Costwasnotcitedasabarrier.88.9% of people gave a correct emergency number with geographical variation. Notably, the Europeanemergency number 112 was not well known. Conclusion: PreviousIrishandAmericanpopulationtargetsforCPRtraininghavebeensurpassedinIrelandin2008.Newinternationallyagreedtargetsarenowrequired.Meanwhileolderpeopleandthoseinlowersocio-economic groups should be targeted for training. Awareness of at least one emergency number isvery high in Ireland. Some geographical variation was found and this should be studied further.© 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Survival from out-of-hospital cardiac arrest (OOHCA) remainslow in many developed countries and regional variation has beendemonstrated. 1 Factors cited in explaining this observation arevariation in incidence of disease, its manifestation and secondaryprevention, patient delay and availability of emergency medicalcare including bystander CPR.While demonstrating considerable pace of improvement inmortality from coronary heart disease (CHD), 2 Ireland has low sur-vival rates from OOHCA, 3 undocumented prevalence of bystandercardiopulmonary resuscitation (CPR) and lack of information onprevalence of CPR training. In 2006, the Sudden Cardiac Death(SCD) Task Force in Ireland made a number of recommendationsto improve survival from OOHCA in Ireland including improvingthe links in the chain of survival. 4  A Spanish translated version of the abstract of this article appears as Appendixin the final online version at doi:10.1016/j.resuscitation.2009.05.023. ∗ Corresponding author. Tel.: +353 1 6352071; fax: +353 1 6352103. E-mail address: (S. Jennings). The aim of this study was to establish baseline information onreadinessintheIrishpopulationtoundertakethefirsttwostepsinthe ‘chain of survival’—(i) contacting the emergency services and(ii) initiating CPR. 5 Specifically, we studied the proportion of thepopulation that had attended a CPR training course in the past 5years,clarifiedthewillingnesstoundertakeandbarrierstotraininCPRaswellasascertainingthelevelofknowledgeoftheemergencytelephone numbers in Ireland. 2. Methods A cross-sectional study, using in-home face-to-face question-naire, was undertaken in 2008. The study used a market researchomnibus approach with quota sampling reflecting age, gender,social class 6 and geography of Ireland. A total of 974 respon-dents exceeded the sample size required assuming a prevalenceof 10% CPR training and an error factor of <2%. Questions from the2006BritishHeartFoundationsurvey 7 wereused,withpermission,to facilitate comparability with UK and Northern Ireland. Ethicalapproval was granted locally.Statisticalanalysiswithsignificanceat  p <0.05,usingSAS(v9.1),established (a) comparability of the sample with the Irish popula-tion and (b) the characteristics of respondents who received with 0300-9572/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.resuscitation.2009.05.023  1040  S. Jennings et al. / Resuscitation 80 (2009) 1039–1042  Table 1 Knowledge of emergency number and CPR training in last 5 years.Variable  N   (%) in Omnibus survey Correct knowledge of emergency no. Significance a CPR training in last 5 years Significance a Age16–24 164(16.8) 147(89.6)NS38 (23.2)Sig. ** 25–44 404(41.5) 353(87.4) 122 (29.3)45–64 280(28.7) 251(89.6) 62 (22.1)65+ 126(12.9) 113(89.7) 7 (5.6)GenderMale 476(48.9) 417(87.6)NS 111 (23.3)NSFemale 498(51.1) 447(89.8) 118 (23.7)Social classAB 126(12.9) 115(91.3)NS39 (31.0)Sig. ** C1 282(29.0) 257(91.1) 88 (31.2)C2 254(26.1) 214(84.3) 58 (22.8)DE 237(24.4) 213(89.9) 35 (14.8)F 75(7.7) 65(86.7) 9 (12.0)LocationDublin 244(25.1) 219(89.8)Sig. * 57 (23.4)NSLeinster (excl Dublin) 263(27.0) 222(84.4) 63 (24.0)Munster 279(28.6) 263(94.3) 53 (19.0)Connacht/ulster 188(19.3) 160(85.1) 56 (29.8)Total 974 864(88.7%) 229 (23.5%)NS=not significant. a Chi-square test of association. *  p -Value<0.01. **  p -Value<0.0001. thosewhodidnotreceiveCPRtraininginthelast5yearsaswellasrespondents who knew versus those who did not know the correctemergency number(s) in Ireland. 3. Results  3.1. Cardiopulmonary resuscitation (CPR) training  The prevalence of those trained in CPR within the last 5 yearswas23.5%with10.6%trainedwithintheprevious2yearsand27.6%ever receiving CPR training in the past.In the group trained in the last 5 years, respondents over 65years of age and those from lower social classes (C2, DE, F) weresignificantly less likely to be trained (  p <0.0001) though no genderor geographical difference were found (Table 1). Most respondents (63.8%) were required to train for work or other commitments.86.5%ofrespondentsreceivedhandsontraining(withmannequin)with 12.2% being trained with a video or by demonstration only.Work was the main source of awareness of CPR training (49.3%)inthosetrainedduringthepast5yearsfollowedbyfriend/colleague(15.7%), school/college (12.2%) and the sports and leisure environ-ment (11.8%). The media or usual health sources, such as GeneralPractitioner (GP) surgeries, were mentioned infrequently.Seventy percent of those who received CPR training in the last5 years said they would have no difficulty administering CPR in anemergencyalthough16.6%hadconcernssuchaslackofconfidence,fear of being sued or getting infection. There were no demographicdifferences between the willing and the concerned/unsure groups.In those who had not received CPR training in the last 5 years( n =745) the most common reason for not receiving training waslack of awareness of the need for CPR training (53%) with respon-dents citing such reasons as ‘never thought about it’, ‘would notknowwheretogoforit’and‘donotknowenoughaboutit’.Afurther33% of this group gave more pessimistic responses such as ‘wouldnot be physically able’, ‘afraid of being sued or getting infection’,and ‘do not want the responsibility’. Cost was cited as a reason byonly four respondents.At the time of conducting the omnibus survey 76 (7.8%) respon-dents were working as health professionals and a further 33 (3.4%)were working in non-health care uniformed positions (healthprofessionals included: doctors, nurses, ambulance profession-als, dentists, dieticians, occupational therapists, physiotherapists,radiographers. Uniformed professionals included: Garda (Police),civildefence,defenceforces/army,retainedfireservices,uniformedsecurity personnel, voluntary ambulance personnel). These twogroups had a combined CPR training prevalence in the past 5 yearsof 55% with a similar proportion (72% of those trained) as the gen-eral population willing to initiate CPR.  3.2. Contacting the emergency services Either one or both of the correct emergency numbers in Ireland(999, 112) were known by 864 (88.9%) respondents with a further68(7%)givingcombinationsofcorrectandincorrect(911)numbersand4.3%unsureofthenumbers.Nosignificantdifferencewasnotedacross age groups, gender or social class though regional variationwas evident (Table 1). Notably, the European emergency number112 was not well known (given as a correct emergency number byonly 15% of people). 4. Discussion Almost one quarter of the Irish population has undergone CPR training in the past 5 years as evidenced in this study with dou-ble this rate in health and uniformed professionals (55%). Mostrespondents in this study (96%) are aware of a correct emergencynumber.The prevalence of CPR training within 5 years (24%) has sur-passed the Irish target of ten percent of the adult populationbetween 1993 and 1997 set out by the Irish Heart Foundation 8 aswell as the 20% target proposed by the American Heart Associa-tion in the 1980s. 9 Also, this rate compares well with New Zealand(27%), 10 the United Kingdom (27%) and Northern Ireland (19%) 7 with the only higher rate published for Western Australia (58%). 11 The prevalence of ever receiving CPR training is documented inmanymorecountriesandrangesfrom2%inHongKong 12 to75%inPoland 13 andNewZealand 10 comparedwith28%inthisIrishstudy.  S. Jennings et al. / Resuscitation 80 (2009) 1039–1042  1041 Many of the demographic findings in this study are similar tothoserecordedinotherinternationalstudieswitholderagegroupsand lower social class respondents less likely to be trained.  7,12–15 Furthermore, most studies report a similarly high degree of will-ingness among the trained to perform CPR, if required.Notably, work or other activity requirements are the majorfactor in participating in CPR training being cited in 60–75% of respondentsinstudiesinmanycountries. 7,12,16 Furthermore,workwas mentioned as a major source of awareness of CPR trainingamong those trained in Ireland followed by information through afriend/colleaguecomparedwiththeUKstudyinwhichawidervari-ety of sources were mentioned with a greater emphasis on school,college and health settings as sources. Paradoxically, those not atwork, mainly the population over 65 years, are more likely to haveCHD or be a spouse of a person with CHD and, are least likely tohave CPR training. Solving this paradox presents a real challenge.Reasons for not being trained in CPR in this study also differedfromtheUKstudyasahigherpercentageinIrelandwereunawareorlacked information on how to be trained. Interestingly, the reasonsfor not being trained in Northern Ireland were similar to those inour study suggesting the need for similar awareness-raising on theisland of Ireland.This is a self-reported, descriptive survey. Validation of train-ing was not undertaken. Potential sources of bias include recall asa result of asking respondents about training in the past 5 yearsas well as selection bias due to quota rather than random sam-pling. Nonetheless information on the prevalence of CPR traininginIrelandisscarcemakingthis,toourknowledge,thefirstnationalstudy to explore this area, though one rural survey in the 1993recorded a prevalence of ever receiving CPR training of 19%. 8 R eg-ular surveillance of the prevalence of CPR training and the levels of recurrent training is important in tracking changes in the ‘chain of survival’yetnosystematicapproachistakenacrosstheEUorviatheInternationalLiaisonCommitteeonResuscitation(ILCOR) 17 thoughmostcountriesundertakenationalhouseholdsurveyswhichcouldincorporate questions about CPR training.With a very high proportion of the population aware of thenational or international emergency number a small but signifi-cant geographical variation is not easily explained. The pattern of decline in knowledge with increasing age was not evident in thisstudy unlike a study from Queensland, Australia. 14 An outstand-ing question, not addressed by this study, is whether bystanderknowledge of the emergency number translates into immediatecall for the emergency services in response to a suspected cardiacarrest.Awareness of the EU emergency number (112) as an emergencynumber in Ireland was low (15%). A recent survey across EU-27countries 18 on the knowledge of 112 as an emergency numberacrossEuropeshowedthatonly41%ofEuropeanswereawareofthiswith only 14% aware in Ireland. This lends credence to the resultsof this study.While there are many aspects for improving OOHCA one areafor further consideration is to address the setting of a targetfor community CPR training in the population. Factors to betakenintoconsiderationinclude(a)themathematicalaspects—theproportion of the population needed to be trained to providesufficient bystanders willing to do CPR, (b) the attitudes in apopulation—normalising the response to a cardiac arrest, (c) thepractical finding—that most people train because of a require-ment at work or other commitments, and (d) understanding thereality—middleagedandoldergroupsaremorelikelytoencountera cardiac arrest as most occur in older people at home. 3,19,20 Weadvocate that this question be approached in an evidenced basedmanner to ensure concordance between the need for a populationtrainedandwillingtoconductCPRwheninanemergencysituationand the need for high survival from OOHCA. Conflict of interest None of the authors have any conflicts of interest.  Acknowledgements Millward Brown IMS Market Research Company, and StephenieLechey, British Heart Foundation.  Appendix A. Omnibus strategy  Omnibus is an internationally proven research methodology,and is widely used in cases where there is a requirement to aska relatively small number of questions of a large, representativesample of the population.  A.1. Face-to-face omnibus The principle features of the face-to-face survey are as follows: •  Interview 1000 adults aged 15+. •  The sample is quota controlled to be nationally representative of the adult population. •  All interviews are conducted face-to-face, in-home. •  Interviews are conducted at 64 sampling points nationwide.Each survey is typically 20–25min long, and usually comprisesaround 8–10 individual sections. The sections will cover a rangeof topics, including, for example, mobile phones, car insurance,cigarette smoking and soft drinks.The process followed for each face-to-face omnibus survey is asfollows: •  When all individual sections (questionnaires) are confirmed, theomnibus team puts them together in the most logical sequence,and checks for overall sense and flow. •  The questionnaire and showcards are printed and prepared fordespatch. •  The Field Department receives sampling points from the Sam-pling Unit and allocates assignments of questionnaires tointerviewers who live in the environs of those sampling points. •  Detailed interviewer briefing notes are prepared and despatchedwith the questionnaires, and each interviewer is briefed person-ally by a Field Supervisor over the telephone. •  Individual quota sheets (with detailed quotas on gender, age andsocial class) are prepared for each interviewer at each samplingpoint and are despatched with the questionnaires. •  Interviewers complete their assignment of interviews by goingto the selected area, knocking on doors, and seeking people’s co-operation.Selectionofrespondentsistotallyrandomwithinthatarea (but keeping to the demographic quotas). •  Field Supervisors keep in touch with interviewers by phone dur-ing the course of the interviewing, to answer any queries theymay have. •  Questionnairesarereturnedbypost,checkedandedited,andsentfor Data Entry. •  Data is sent electronically from our Data Entry Unit to our DataProcessing Unit. •  Our Data Processing Unit produce data tabulations for the ClientService Team, based on the latter’s precise specification. •  TheClientServiceTeamchecksthedatatabulationsandproducesa charted presentation and report for the client. •  A 10% back check is conducted on all completed interviews as aquality control measure.  1042  S. Jennings et al. / Resuscitation 80 (2009) 1039–1042 The face-to-face omnibus is fully nationally representative. Aface-to-faceapproachisalsotheonlymethodologywhereanurban/rural definition can be guaranteed. References 1. Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospitalcardiac arrest incidence and outcome. JAMA 2008;300:1423–31.2. O’Hara T, Bennett K, O’Flaherty M, Jennings S. Pace of change in coronary heartdiseasemortalityinFinland,IrelandandtheUnitedKingdomfrom1985to2006.Eur J Public Health 2008;18:581–5.3. Byrne R, Constant O, Smyth Y, et al. Multiple source surveillance incidence andaetiology of out-of-hospital sudden cardiac death in a rural population in theWest of Ireland. Eur Heart J 2008;29:1418–23.4. Reducing the risk: a strategic approach. The report of the task force on suddencardiac death. Dublin: Department of Health and Children (Ireland); 2006.5. 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