Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None applicable.
Task Force Synthesis Citation
Ying-Chih Ko, Ming-Ju Hsieh, Sebastian Schnaubelt, Tasuku Matsuyama, Adam Cheng, Robert Greif on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force.
Disparity in layperson resuscitation education: A scoping review and Task Force Insights: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Teams Task Force, 2022 December 2. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The search strategy was conducted by a librarian at the library of National Taiwan University Hospital, Taipei, Taiwan (H.P.C.) with involvement of the ILCOR Education, Implementation, and Teams (EIT) Task Force Scoping Review team for this scoping review (Y.C.K., M.J.H., S.S., T.M., A.C, R.G.). Current literature associated with disparity in layperson resuscitation education was sought in PubMed, EMBASE, CINAHL, and the Cochrane Library to be considered as relevant publications to the topic. After title screening and full text assessment, data from studies containing evidence on factors influencing layperson resuscitation education were extracted by a dedicated writing group and presented to the EIT Task Force for discussion. The final scoping review’s task force insight was discussed and agreed during EIT Task Force meetings and approved by the ILCOR Science Advisory Committee.
Scoping Review
Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.
PECOST
The PECOST (Population, Exposure, Comparator, Outcome, Study Designs and Timeframe)
Population: Laypersons (non-health care professional)
Exposure (as no Intervention was investigated): Presence of any factors that would possibly enhance or hinder the opportunity for laypersons to undertake resuscitation education
Comparators: Absence of the specific factor
Outcomes: Likelihood of undertaking resuscitation education, including adult/pediatric basic life support (BLS) courses, and the neonatal resuscitation program.
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols), letters, editorials, comments, case reports are excluded. All relevant publications in any language are included as long as there is an English abstract.
Timeframe: All years and all languages were included as long as there was an English abstract; Literature search updated to Aug. 31, 2022.
Search Strategies: EIT 6102 Search Strategies
Data tables: FA 7110 Data tables
PRISMA: EIT 6102 PRISMA
Task Force Insights
- Why was this topic reviewed?
Out-of-hospital-cardiac arrests (OHCA) have a relatively low survival rate while impacting millions of lives globally. {Nolan 2020 S2} Timely administration of resuscitative efforts, such as bystander cardiopulmonary resuscitation (CPR) and the application of an automated external defibrillator, has a significant impact on survival. {Semeraro 2021 80} Therefore, it is crucial to train laypeople in CPR and increase public awareness of cardiac arrest measures to enhance layperson involvement in life-saving attempts. {Van Hoeyweghen 1993 47} Unfortunately, not every individual has equal access to resuscitation education programs and many underserved populations lack access to CPR education. The reasons for these inequities have yet to be fully described. {Birkun 2022 100}
Identifying disparities in access to resuscitation education will provide pivotal guidance for targeted training and potentially increase public layperson involvement in OHCA. Recognizing factors associated with enhancing or hindering the opportunity to attend resuscitation courses might provide insight into possible strategies for improving access to education. In this review, we aim to identify and describe factors that either promote or hinder laypersons from attending resuscitation education courses.
- Narrative summary of evidence identified
An extensive search of the databases yielded 8,017 citations. (Figure 1) After removing duplicates and article screening, 79 articles were included for full-text review, which resulted in 22 studies being included in this review (Table.1). {Abdulhay 2019 13, Alexander 2019 9, Anderson 2014 194, Andrell 2021 100071, Axelsson 2006 90, Bakke 2017 6, Birkun 2018 237, Blewer 2017 e006124, Cartledge 2020 e033722, Chair 2014 126, Dobbie 2018 e0193391, Flabouris 1996 95, Hatzakis 2008 165, Hawkes 2019 e008267, Jennings 2009 1039, Jensen 2022 167, Kuramoto 2008 475, Lejeune 1987 224, Meischke 2012 176, Owen 2018 100, Sipsma 2011 564, Teng 2020 e041245} We found 19 cross-sectional studies {Abdulhay 2019 13, Alexander 2019 9, Andrell 2021 100071, Axelsson 2006 90, Bakke 2017 6, Birkun 2018 237, Blewer 2017 e006124, Cartledge 2020 e033722, Chair 2014 126, Dobbie 2018 e0193391, Hatzakis 2008 165, Hawkes 2019 e008267, Jennings 2009 1039, Kuramoto 2008 475, Lejeune 1987 224, Meischke 2012 176, Owen 2018 100, Sipsma 2011 564, Teng 2020 e041245} and three retrospective cohort studies. {Anderson 2014 194, Flabouris 1996 95, Jensen 2022 167} All studies were related to resuscitation training for adults, with publication years ranging from 1987 to 2022. Seven studies were conducted in North America {Abdulhay 2019 13, Alexander 2019 9, Anderson 2014 194, Blewer 2017 e006124, Meischke 2012 176, Owen 2018 100, Sipsma 2011 564}, ten in Europe {Andrell 2021 100071, Axelsson 2006 90, Bakke 2017 6, Birkun 2018 237, Dobbie 2018 e0193391, Hatzakis 2008 165, Hawkes 2019 e008267, Jennings 2009 1039, Jensen 2022 167, Lejeune 1987 224}, and five in the Asia-Pacific region {Cartledge 2020 e033722, Chair 2014 126, Flabouris 1996 95, Kuramoto 2008 475, Teng 2020 e041245}.
A thematic assessment of enablers or barriers to attend CPR education resulted in grouping the found factors into three main themes: personal, socioeconomic and higher education, and geographic factors (Table 2.)
Personal factors
We found 18 articles addressing the effect of layperson age on resuscitation education. {Alexander 2019 9, Anderson 2014 194, Andrell 2021 100071, Axelsson 2006 90, Bakke 2017 6, Blewer 2017 e006124, Cartledge 2020 e033722, Dobbie 2018 e0193391, Hatzakis 2008 165, Hawkes 2019 e008267, Jennings 2009 1039, Jensen 2022 167, Kuramoto 2008 475, Lejeune 1987 224, Meischke 2012 176, Owen 2018 100, Sipsma 2011 564, Teng 2020 e041245} Younger laypersons, especially those of working age, were more likely to receive resuscitation education compared to older individuals. {Alexander 2019 9-15, Anderson 2014 194-201, Andrell 2021 100071, Axelsson 2006 90, Bakke 2017 6, Blewer 2017 e006124, Cartledge 2020 e033722, Dobbie 2018 e0193391, Hatzakis 2008 165, Hawkes 2019 e008267, Jennings 2009 1039, Jensen 2022 167, Kuramoto 2008 475, Lejeune 1987 224, Owen 2018 100, Sipsma 2011 564}
Differences in sex and attendance of CPR courses were found in 16 studies with inconclusive results. {Alexander 2019 9, Andrell 2021 100071, Axelsson 2006 90, Bakke 2017 6, Birkun 2018 237, Blewer 2017 e006124, Cartledge 2020 e033722, Chair 2014 126, Dobbie 2018 e0193391, Hawkes 2019 e008267, Jennings 2009 1039, Jensen 2022 167, Meischke 2012 176, Owen 2018 100, Sipsma 2011 564, Teng 2020 e041245} Three studies reported higher CPR training rates for men {Bakke 2017 6, Birkun 2018 237, Jensen 2022 167} and three for women {Andrell 2021 100071, Hawkes 2019 e008267, Sipsma 2011 564}, but ten report no differences or inclusive results. {Alexander 2019 9, Axelsson 2006 90, Blewer 2017 e006124, Cartledge 2020 e033722, Chair 2014 126, Dobbie 2018 e0193391, Jennings 2009 1039, Meischke 2012 176, Owen 2018 100, Teng 2020 e041245}
Race as a background factor was reported in four studies. {Alexander 2019 9, Anderson 2014 194, Blewer 2017 e006124, Owen 2018 100} Three of the studies were derived from results of the same cross-sectional questionnaire of nationally representative adult respondents in the USA, showing that Hispanic/Latino citizens were less likely to be CPR trained compared to white citizens, without any difference when compared to other non-white populations. {Alexander 2019 9, Blewer 2017 e006124, Owen 2018 100} One cohort study reported that more black or Hispanic residents in a community was associated with lower CPR training rates.{Anderson 2014 194} Some studies report language skills as a barrier to receiving CPR training. {Flabouris 1996 95, Meischke 2012 176} Moreover, studies identified that being married, not having children, and having witnessed a collapsed person were facilitators to training. {Hawkes 2019 e008267, Jensen 2022 167, Kuramoto 2008 475}
Socioeconomic and higher education factors
Education attainment was investigated in thirteen studies {Abdulhay 2019 13, Alexander 2019 9, Anderson 2014 194, Andrell 2021 100071, Birkun 2018 237, Blewer 2017 e006124, Cartledge 2020 e033722, Chair 2014 126, Hatzakis 2008 165, Meischke 2012 176, Owen 2018 100, Sipsma 2011 564, Teng 2020 e041245}, and twelve of them indicated that people with high levels of education or more years of education are more likely to be trained in CPR {Abdulhay 2019 13, Alexander 2019 9, Andrell 2021 100071, Birkun 2018 237, Blewer 2017 e006124, Cartledge 2020 e033722, Chair 2014 126, Hatzakis 2008 165, Meischke 2012 176, Owen 2018 100, Sipsma 2011 564, Teng 2020 e041245}, while one study showed no difference. {Anderson 2014 194}
Lower income was shown as a barrier in four studies {Abdulhay 2019 13, Anderson 2014 194, Blewer 2017 e006124, Teng 2020 e041245}, and increased household income was not associated with an increase in AED training in one nationwide cross-sectional questionnaire survey. {Owen 2018 100}
Societal class was addressed in three studies, revealing that lower social grades were less likely to have been trained in resuscitation. {Dobbie 2018 e0193391, Hawkes 2019 e008267, Jennings 2009 1039} Occupation status with more likely to receive resuscitation education was addressed in five studies {Axelsson 2006 90, Birkun 2018 237, Chair 2014 126, Hawkes 2019 e008267, Kuramoto 2008 475}; employment status in four {Axelsson 2006 90, Birkun 2018 237, Chair 2014 126, Hawkes 2019 e008267}, being a student in three {Axelsson 2006 90, Birkun 2018 237, Hawkes 2019 e008267}, and one study each investigated military conscripts {Axelsson 2006 90}, or skilled workers {Kuramoto 2008 475}. Having a driver’s license was associated in a cross-sectional study as an enabling factor to attend CPR courses {Kuramoto 2008 475}. One cross-sectional survey reported that the implementation of mandatory high school CPR training in the United States resulted in more adults trained in CPR compared to areas without such legally required school CPR training. {Alexander 2019 9}
Geographic factors
Seven studies report geographic factors (e.g. place of residence, birthplace). {Anderson 2014 194, Andrell 2021 100071, Axelsson 2006 90, Cartledge 2020 e033722, Flabouris 1996 95, Jensen 2022 167, Teng 2020 e041245} Native-born residents were associated with a higher likelihood of CPR training in two studies {Axelsson 2006 90, Cartledge 2020 e033722}, but showed no association in another Scandinavian study. {Andrell 2021 100071} A retrospective Australian study described that communities with larger populations of Southern-European born and South-East Asian born residents had a significantly lower proportion of CPR trainees compared to communities with less of these non-Australian born residents. {Flabouris 1996 95}
Two studies described that living in rural areas was associated with higher CPR training {Axelsson 2006 90, Jensen 2022 167}, which is in contrast to another study. {Anderson 2014 194}. Another study showed no differences if laypersons living in rural or urban areas. {Teng 2020 e041245}
- Narrative Reporting of the task force discussions
Our review investigating disparities in layperson resuscitation education has identified several enablers and barriers. Through recognizing these factors, targeted training initiatives for laypersons with a reduced likelihood of undertaking such resuscitation education may be designed, implemented, and assessed if successful.
Age was a significant factor mentioned in most of the studies showing that younger laypersons or people of working age are more likely to attend CPR training. Obviously, the age group with the most cardiac arrest and their life partner are out of reach to the existing conventional CPR education strategies. Targeted approaches include increasing availability by providing convenient training locations, generating more publicity and awareness of resuscitation, and promoting group or couples’ participation may be considered. {Vaillancourt 2014 700} Targeted and tailored resuscitation education should also be applied to laypersons having small children in the household or during pregnancy, and age-appropriate CPR training can be taught to kindergarten-aged children and schoolchildren. {Böttiger, 2017 6, Lorem, 2008 103; Lukas, 2016 35}
This scoping review found that higher educational and income levels as well as social grade were associated with more resuscitation training. Mandatory school CPR training, more exposure to resuscitation knowledge, the importance of CPR, or occupations requiring resuscitation skills could provide an explanation for this association. Specific targeted training for populations with lower educational standing and/or lower incomes may be beneficial. Mandatory CPR training (i.e. before acquiring a driver’s license) might increase layperson CPR willingness but this effect needs further investigation. {Jensen 2022 167, Juul Grabmayr 2022 100268, Kuramoto 2008 475} Legal requirements for school-based resuscitation education not only increased the training among students but also of adults in such regions {Alexander 2019 9}, implying that legislation is promoting resuscitation and may cause a ripple effect influencing the rate of bystander resuscitative rescue.
People of color did not receive proper bystander resuscitation from laypersons, or even medical staff. { Garcia 2022 1569, Hofacker 2020 42, Moon 2014 1041, Vadeboncoeur 2008 655} Lack of resuscitation education may not be the mere reason to explain that. Deficiency of mutual trust in the community or inadequate language proficiency were speculated as being barriers. {King 2015 308, Liu 2014 131, Sasson 2015 545} An interventional study aiming to teach refugees coming from 19 countries reported that English serving as a universal language was insufficient, and conducting BLS courses in the participants’ native language was optimal. {Schnaubelt 2022 e13644} In general, multifaceted system-wide interventions should be initiated to reduce structural biases or discrimination in racial, ethnic, and cultural differences to increase resuscitation training for all populations living in the communities.
Awareness of public AEDs and previous witnessing of collapsed patients were associated with a higher likelihood of receiving CPR training. {Hawkes 2019 e008267, Kuramoto 2008 475}
The influence of geographic factors (e.g. where they live or were born) and sex is unclear. Disparities in gender, social, cultural, and historical contexts might trigger barriers to education that are of importance. Further studies are needed to shed light on the connection between geographic factors and sex on resuscitation education. The majority of the studies came from highly developed countries and the information from low-resource areas or remote areas requires more investigation.
Our search did not identify any pediatric or neonatal resuscitation educational programs for laypersons or studies including CPR education for children. Also, the task force recognized that no studies addressed factors of teaching or receiving CPR for the mentally or physically disabled, whereas the opportunities to receive resuscitation for the disabled are still crucial. {Birkun 2022 32}
Our scoping review has not identified sufficient evidence to prompt a systematic review or a meta-analysis. However, based on the results of this scoping review and expert opinion from the ILCOR Task Force on Education, Implementation and Teams, we were able to highlight significant gaps in knowledge and open research questions; and to propose educational approaches addressing these influencing factors on laypersons' CPR training in resuscitation. Future work needs to explore in depth barriers and enablers that impact the likelihood of laypersons undertaking resuscitation education, and targeted initiatives to include underserved populations.
Knowledge Gaps
We identified several knowledge gaps in the literature.
- In under-represented or minority populations, respective appropriate resuscitation educational programs need to be developed.
- The influence of geographic factors (e.g. urban or rural areas, low-resource settings and remote areas), sex of laypersons, or the impact of law-requiring CPR training on the attendance of resuscitation education courses remains to be further investigated.
- No study describes factors regarding populations with special needs, such as disabled persons, pregnant women, schoolchildren, or kindergarten-aged children training, and no studies were found in pediatric or neonatal resuscitation.
- The influence of these barriers or enablers on the clinical outcome of OHCA victims remains unclear.
Acknowledgement
The authors acknowledge the assistance provided by Hsin-Ping Chiu, the librarian of the National Taiwan University Medical Library for building up the searching strategy. The following ILCOR EIT Taskforce Members are acknowledged as collaborators on this scoping review: Cristian Abelairas-Gomez, Jan Breckwoldt, Kathryn Eastwood, Nino Fijačko, Elaine Gilfoyle, Kasper G. Lauridsen, Jeffrey Lin, Andrew Lockey, Tasuku Matsuyama, Kevin Nation, Catherine Patocka, Taylor L. Sawyer, Sebastian Schnaubelt, Chih-Wei Yang, Joyce Yeung, and Judith Finn. We would like to thank Peter Morley (Chair ILCOR Science Advisory Committee) for his valuable contributions.
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