The 2015 AHA (American Heart Association) CPR guidelines show that prompt CPR and early defibrillation can effectively improve the survival rate of OHCA patients .
In this questionnaire-based survey among the First Aid eLearning courses participats, we found that only 12.28% mastered the AED knowledge and 86.08% (n=1398) of non-medical related respondents had not previously attended AED training. Most respondents(90.10%) claimed that they would rescue the OHCA, whether they had attended previous AED training before or not (AED trained 90.75%, not AED trained 89.75%). 95.67% of respondents indicated that they would be willing to learn AED use. The top three reasons that they were reluctant to carry out the rescue were lack of practical performing ability (60.47%), fear of hurting patients (59.30%), and inadequate knowledge of resuscitation techniques (44.19%). Additionally, after this online training course, the willingness to perform AEDs has improved among most people.
Public Knowledge of AEDs Use
OHCA is a significant health danger world-wide, but the mortality rates of different countries are significantly unequal, which results from discrepancy of AED penetration. Our study revealed a result that 34.50% of respondents knew what AED stands for, compared with 31.71% in Poland , and 44.5% in Slovenia . In addition, half (50.02%) of the respondents could answer none of the questions about knowledge of AEDs use while merely one eighth (12.28%) could answer all the questions correctly. Considering these questions are fundamental to AEDs use, the key deficiencies as indicated might partly contribute to the low performance rate of bystander AED and thus low survival rate of OHCA in China, in view of studies showed that adequate knowledge leads to more positive attitudes toward performing CPR and AEDs [16, 17]. In fact, AED training programs have been developed in many countries, such as the United States , Sweden and Japan [19, 20], resulting in a great improvement of survival rate of OHCA patients. But we still face some intractable problems, such as low AED penetration, public lack of knowledge, and lack of awareness of first aid skills.
Another finding is that only 17.37% medicine related respondents could answer all questions about AEDs use correctly, slightly higher than those who are not (10.43%), astonishingly low when compared with Japan, where most medical students are familiar with AEDs . In China, CPR training course is compulsory education for all medical students, whereas merely 67.01% of medical related respondents in our survey had attended a previous AED training course, possibly because most respondents had not yet arranged to learn CPR and AED use before our survey, and would study it in future curriculum.
AED Training and Age Aspects in Knowledge of AEDs
The proportion and ways of AED training vary in different countries. We found 36.69% had attended a previous AED training course in our survey, versus 4.9% and 15.2% in 2016 among Chinese public [22, 23], revealing a great improvement on knowledge penetration these years. However, those figures fall short of that published in Japan, Norway, and Slovenia where the proportion of people who have received training in resuscitation techniques more than once were 70%, 89%, and 64% respectively. [13, 21, 24]. Such courses have become a compulsory curriculum . Not surprisingly, respondents with previous AED training proved to have better knowledge of AEDs, but only 19.45% could answer all questions correctly. One possible reason is that their last training course was some time ago. Another reason is the training course is not effective enough to provide proper instruction in operating AEDs. Many studies demonstrated that repeated CPR training can strengthen not only the effectiveness of training courses but also the confidence and willingness to perform bystander resuscitation, and that the optimal interval between classes should be less than 5 years [25, 26]. In a whole, AED training should be implemented as a part of compulsory education, not only with proper instrument, but also with professionals to offer correct information. In addition, the first aid education is not accomplished of an action, multiple training in an appropriate interval is necessary.
After stratification into four age groups (＜18 years; 18-35 years; 35-50 years; >50 years), our study also showed that respondents of 18-35 years old account for the highest proportion in having previous AED training (38.37%), consistent with other studies, while a huge gap was observed between of respondents willing to learn(95.67%) and respondents actually having been trained(38.37%). This discrepancy can obviously be associated with few approaches of AED knowledge dissemination in Chinese public. According to the major reasons for respondents unwilling to attend a training course were “not knowing where the CPR training courses are” and “a lack of time and concern” , it is a possible way to add compulsory education about first aid techniques and refresh these classes to develop both recognition and awareness of importance.
However we found that respondents of 35-50 years old had the best knowledge of AEDs rather than the most trained respondents among 18-35 years old, which is inconsistent with a previous study in Poland . This may be because people 35-50 years old are more likely to suffer heart disease, so they will subconsciously pay more attention to related knowledge. Moreover, another fact is that people use television (39%) and books (29%) rather than first aid training courses as the predominant ways to learn CPR and AEDs in China , which may infer the insufficiency of training effectiveness. Therefore, even though the 18-35 years old group had a higher previous training rate, their knowledge of AEDs may not be guaranteed to be better. In many parts of China, the education of first aid techniques are drawn back by the lack of proper instructions and equipment, resulting in much less effective AED classes. Even for those who have attended AED training and had truly mastered the performance, the oblivion after years could be an obstacle when performing first aid to OHCA victims.
Willingness and influencing factors in helping OHCA
Our results indicated that 90.10% respondents were willing to rescue OHCA patients, regardless of their relationship with the patients and whether it is obliged to perform CPR with mouth-to-mouth ventilation. This percentage is much higher than those in previous studies [29, 30]. Interestingly, although the knowledge of AEDs was significantly different between trained and untrained respondents, we observed no difference of willingness to rescue between these two groups, which is consistent with other studies [21, 23]. Differing from other studies [31-33], we found females were more willing to rescue OHCA patients than males regardless of the required skill(p<0.05). We assume that this difference in gender is owing to their different principal concern, as shown in other studies that more males feared legal dispute while more females lacked confidence [22, 27]. Despite a bit of differences between people who are medical related or not, the Chinese public still express high willingness to help OHCA patients.
The Reasons for Reluctance to Rescue OHCA Patients
More than 11% of our respondents refused to help OHCA victims, and we highlighted various reasons why respondents were reluctant to rescue OHCA patients. The top three reasons were lack of practical performing ability (60.47%), fear of hurting patients (59.30%), and inadequate knowledge of resuscitation techniques (44.19%). We assume all reasons above can be summarized as ‘lack of confidence of precise implementation’. Training in resuscitation techniques has been proven to improve public knowledge and positive attitudes toward bystander CPR and operating AEDs. In this way, the public first aid education is of an urgent need and more professional and comprehensive training programs should be taken into action.
The following reasons(36.04%) included legal responsibility, not professionally licensed, and fear of being swindled. Since the General Principles of the Civil Law of China was put into effect in 2017, there is a law to protect rescuers from liability when their attempts to rescue lead to certain kind of damage to the OHCA patients in the process, which might markedly eliminate these kinds of concerns. Similar regulations, like the “Good Samaritan Law” in the United States, Canada and many European countries, guaranteeing rescuers legal rights, promoting interest and sense of security of bystander CPR and AED operations, have exerted a great effect on improving the survival rate of OHCA patients . With the improvement of the 2017 law, it is predictable that less concern for legal responsibility will be seen in the near future.
Other reasons for reluctance is unwilling to contact with strangers(15.12%). We infer that the fear of disease transmission and feeling embarrassed contribute to the psychological rejection, which have been mentioned in other studies [21, 22, 24]. The proportion of respondents worried about disease transmission was 3% in Japan , 16% in Tianjin, China, and 46% in Norway [22, 24]. Some cultural or psycho-social factors have been reported to be relevant to the declining to rescue due to feeling embarrassed in China . Therefore, how to combine resuscitation measures with Chinese traditional customs effectively remains a problem at present.
The main limitation of this study is the selection of the respondents. A high proportion of young people in the respondents were investigated by network questionnaires, which may lead to the results could not fully reflect the average level of present condition. However, this group of people will be the main body of the future population, so the results could reflect the level of the condition in the near future.