Our study population represents urban residents who are able to 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 lay participants had heard of bystander CPR, compared to about 90% found in studies in other Asian countries.9–10, 12 This suggests the need for better CPR recognition in Thailand. However, the 45.6% of lay participants who had taken a CPR course was comparable with the findings of previous studies.9–10, 12 Two-thirds of HCPs and 13.6% of lay participants expressed CPR self-efficacy, which may affect their willingness to perform CPR.
These results show that the COVID-19 pandemic has reduced the willingness of bystanders to perform compression-only or conventional CPR in Thailand, despite it being a low-risk country. By contrast, a previous systematic review could not provide a firm conclusion as to the effect of COVID-19 on bystanders’ willingness to perform CPR. While studies from Western countries have shown lower rates of bystander CPR, results from Asian countries have been inconsistent.17, 21–23 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 had a greater impact on participants’ willingness to perform conventional CPR (50% reduction) than compression-only CPR. Similar reductions were seen in the willingness to perform mouth-to-mouth, mouth-to-face mask, or mouth-to-pocket mask ventilation. Although the percentage of reduction in HCPs was greater than in lay participants, willingness to perform ventilation was comparable between the two groups. The fact that ventilation is an aerosol generation procedure (AGP), might cause participants (especially HCPs) to be wary of the risk of COVID transmission. Similarly, the lack of clarity as to whether chest compressions and defibrillation are AGPs may have affected participants’ willingness to perform these procedures.24 Although our study took place during a period in which Thailand had few COVID cases. New cases in each day were between 0–22 cases. However, the lack of an available vaccine may have contributed to participants’ reluctance.
We also found that the participant's relationship to the victim affected their willingness to perform CPR. While lay participants were equally willing to perform conventional CPR on family members and acquaintances, this was not true of HCPs, possibly out of fear of transmission. This suggests that relationship to the victim may be a more significant factor for HCPs than laypeople. Participants in both groups were least likely to perform CPR on strangers, which is consistent with other studies.
Overall willingness to perform CPR (pandemic and non-pandemic) in our study was lower than in previous studies.7, 9–11 This may have been partly due to insufficient CPR knowledge and low CPR self-efficacy in lay participants. A cultural fear of making mistakes may have been another factor, as may particularly laws of a country and citizens’ awareness of them. In some Western countries, it is fairly well known that Good Samaritan laws protect bystanders who perform CPR, whereas a previous study in Hong Kong showed that only 12.1% of the population were aware of a Good Samaritan Law concept.25 While Good Samaritan law is enforced in Thailand in the year 2015.
Factors associated with willingness to perform compression-only CPR in our study were being an HCP, having high CPR self-efficacy, and having good CPR knowledge. Being single was also associated with higher willingness, but only with family members and acquaintances. However, good CPR knowledge was the only factor associated with willingness to perform conventional CPR. Despite this, being an HCP (roughly half of whom had good CPR knowledge) was not associated. Younger participants and students were less willing to perform compression-only CPR. However, our sample size was not large enough to determine a conclusive association. We did not find any correlation with gender, marriage status, education, work status, or experience with CPR training, as have previous studies.8, 9, 13–14
Our results showed that 70–90% of participants would refuse to perform conventional CPR during the pandemic, and 60–95% would refuse to perform ventilation despite including a description of the ventilation technique and its benefits in the survey. In HCPs, 72.2–82.5% were willing to perform compression-only CPR compared to 17.3–35.1% for conventional 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 Thai bystanders to perform CPR.
One limitation in this study was selection bias, as those interested in CPR or with CPR knowledge were more likely to participate in the survey, thus affecting the results. In addition, willingness to perform 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 willingness to perform bystander CPR as a representation. Furthermore, although a high percentage of the Thai population have internet access, the fact that our survey was conducted online means that our participants were likely disproportionately urban and in the middle to high socioeconomic class, as it required a smartphone or computer with reliable internet. Despite these limitations, our study provided data regarding the impact of the pandemic and the relationship between bystanders and the victim on willingness to perform CPR.