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Social attitude and willingness to attend cardiopulmonary resuscitation training and perform resuscitation in the Crimea

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Alexei Birkun1, Yekaterina Kosova2


1 Department of Anaesthesiology, Resuscitation and Emergency Medicine, Medical Academy named after S. I. Georgievsky of V. I. Vernadsky Crimean Federal University; 295051, Lenin Blvd, 5/7, Simferopol, Russian Federation


2 Department of Applied Mathematics, Taurida Academy of V. I. Vernadsky Crimean Federal University; 295007, Prospect Vernadskogo, 4, Simferopol, Russian Federation


Corresponding Author: Alexei Birkun, Email: birkunalexei@gmail.com


© 2018 World Journal of Emergency Medicine


DOI: 10.5847/wjem.j.1920–8642.2018.04.001


BACKGROUND: To promote potentially life-saving bystander cardiopulmonary resuscitation (CPR), the proportion of CPR-trained general public and their attitude toward CPR should be assessed, which is yet to be done in the former Soviet Union countries. As a case study, the survey is aimed to investigate the prevalence of CPR training, CPR knowledge, attitude and willingness to attend training and attempt CPR in the general population of the Crimea.

METHODS: A personal interview survey was done from November 2017 to January 2018 with quota sampling reflecting age, gender and territorial distribution of the Crimean population.

RESULTS: Out of 384 persons surveyed, 53% were trained in CPR. Of trained, 24% passed training within the last year, 44% attended a single course. Among the non-trained, 51% never thought about the need to attend training. Knowledge of CPR is generally poor. About 52% wish to learn CPR, 79% and 91% are willing to attempt CPR on a stranger or a loved one, respectively. Lack of knowledge is the strongest barrier to attempt CPR. People aged ≥60, those with educational level lower than high school, widowed and retired are mostly untrained and unwilling to learn CPR. Females and unemployed are mostly untrained, but willing to be educated.

CONCLUSION: There is a need for increasing CPR training and retraining, and improving awareness and motivation to learn CPR in the Crimean population, targeting the least trained groups. The results could be used as a reference point for future studies in the former USSR countries, utilising the same methodology.

(World J Emerg Med 2018;9(4):237–248)


KEY WORDS: Cardiopulmonary resuscitation; Cardiac arrest; First aid; Training; Survey



Out-of-hospital cardiac arrest (OHCA) is recognized as a significant public health problem throughout the world.[1–4] In North America and the European Union, the incidence of OHCA cases, attended by emergency medical services (EMS), is currently reported to be as high as 84–98 per 100,000 population-years, and survival is ranging from 30% to less than 5%.[3,5] Though little is known about the epidemiology of OHCA in most Eastern European countries, cardiovascular diseases constitute the leading cause of mortality in the Russian Federation[6] and Ukraine,[7] and recent data suggest high incidence of OHCA with low efficiency of cardiopulmonary resusci tation (CPR) in the Cr imea, [8] where the management of public health services has passed from Ukraine to Russia since 2014.

Without early intervention, the chance of survival from OHCA falls by 7%–10% per minute,[9] while the median interval for EMS arrival is 5–8 minutes.[10] Immediate bystander-initiated CPR and defibrillation are essential to improve survival in OHCA.[10] However, attitudes towards CPR and willingness to perform CPR vary widely between populations,[4,11,12] and yet, many communities[2,3,13] report low bystander CPR rates. Effective education of the general public on how to perform CPR properly may increase the number of people willing to undertake CPR in real life and improve survival, and training of lay people in CPR is currently acknowledged as a primary educational goal in resuscitation.[14]

In order to improve bystander CPR rates in the community, knowledge of current population's training status, attitude, willingness and barriers to get training and perform CPR is necessary.[12] However, in the former USSR countries (including Russia and Ukraine), thus far no studies have investigated the proportion of general public that has undergone CPR training and their willingness to attempt CPR and attend CPR training.

This observational, descriptive, cross-sectional survey was aimed, as a case study, to investigate previous CPR training and knowledge, attitude and willingness to get trained in CPR and to perform CPR in the general population of the Crimea.



Study sample

The survey was conducted from November 2017 to January 2018 in the territory of the Crimean peninsula, located on the northern coast of the Black Sea. The target population included 1.9 million permanent residents of the Republic of Crimea and the city of Sevastopol aged ≥18 years.[15,16] We used a quota sampling approach to reflect population age, gender, geographic distribution (northern, western, southern, eastern, central Crimea and Sevastopol) and place of residence (urban/rural) according to the latest population census.[15,16] The sample size needed to reflect the target population with a ±5% margin of error at a 95% confidence level was calculated as 384 using the Cochran formula.[17]



The structured 26-item questionnaire was designed for personal interview. Initial section of the questionnaire asked about previous CPR training, reasons for not attending any CPR training, willingness to learn CPR and potential motivating factors for future training. Further, willingness to attempt CPR in real life was evaluated using a 5-point numeric rating scale (from 1 – definitely will not do CPR to 5 – definitely will do CPR), and potential barriers to perform CPR on a stranger or a friend/relative were inquired with multiple-choice questions. General CPR knowledge was first self-rated by respondents on a 5-point scale (from 1 – no knowledge to 5 – very good knowledge). Further, two openended questions were asked to assess the participants' knowledge of CPR in terms of hand placement and rate for chest compressions. The experience of real-life cardiac arrest, participants' health status and existence of health problems in relatives were also queried. The ending section of the questionnaire collected demographic data, including age, marital status, educational background, occupation and total monthly income.

The questionnaire was pilot-tested for readability and unambiguity in a group of 10 lay persons, and minor corrections were made to improve. To assess testretest reliability, the questionnaire was administered two times to 21 persons with an interval of 14 days, and the reliability was considered as good (Cronbach's alpha=0.89; 95% confidence interval [CI] 0.64–0.96). The questionnaire was not tested for internal consistency because the individual items were not expected to be measuring similar or directly related constructs.

Interviews were conducted personally by 10 trained interviewers in public places. Potential respondents were asked if they would like to answer a series of questions related to their attitude and willingness to provide first aid to a victim in cardiac arrest. There was no conflict of interest between the respondents and the survey. All respondents provided their informed verbal consent for participation. The institutional review board reviewed the questionnaire and approved this study.


Statistical methods

We first performed descriptive statistics for the respondents' characteristics. The characteristics were then compared with regard to previous CPR training status, CPR knowledge, willingness to attend CPR training and to perform CPR by chi-square test or Fisher 's exact test, as appropriate. The strength of association was measured using the Cramér 's V or phi coefficient. The following values were used to interpret the measures of association: 0.1 – small, 0.3 – moderate, 0.5 – large.[18] Further, variables with confirmed association (P<0.05) were included in a binomial logistic regression analysis to determine the set of factors associated with previous resuscitation training, willingness to attend training and willingness to attempt CPR, and results were expressed as odds ratios (OR) and 95% CI. Variables considered collinear were excluded. P-values <0.05 represented statistically significant differences. Statistical analyses were performed with IBM SPSS Statistics 23.0 (IBM Corporation, USA).



A total of 459 questionnaires were administered by interviewers. Eight questionnaires contained incomplete or contradictive answers and were excluded. There were only 25 cases of refusal to participate in the survey or early interruption of the interview, producing the response rate of 95%. Seventy five questionnaires were oversampled and, being considered as a duplication of respondents' demographic categories, were excluded from analysis in order to preserve representativeness of the population under study. Finally, 384 original and correctly completed questionnaires were selected for the analysis.



The distribution of respondents by socio-economic and demographic characteristics is presented in Table 1. Among the respondents, 45% were male. Urban population accounted for 59% of the survey participants. Most respondents were married (60%), with college/ technical school education or higher (82%), employed or self-employed (61%). Six percent (n=22) had professional medical education. The monthly income was most commonly (32%) reported to be ≥10,000 - <20,000 rouble (RUR).


Approximately 1% estimated their own health as very poor, 6% – as poor, 47% – satisfactory, 40% – good, and 6% – very good. Thirty four percent (n=130) confirmed that their relatives or friends currently have serious health-related problems.

About 78% (n=298) respondents had no experience of real-l ife cardiac arrest si tuations. Among the respondents who had previously witnessed cardiac arrest (n=81), 77% (n=62) were bystanders not participating in the CPR attempt and 23% (n=19) participated in providing CPR in real life. Out of those who witnessed cardiac arrest, 28% (n=23) stated the victim was their loved one, and 5 of 23 (22%) attempted CPR.


Previous CPR education

Of the respondents, 53% (204/384) reported previous resuscitation training (chest compressions or rescue breathing) (Table 1). All respondents having professional medical education were previously trained in CPR.

Based on univariate analysis, the status of previous CPR training was associated with sex, age, marital status, educational level, occupation, medical background and monthly income (small to moderate association), but independent from the place of residence (urban vs. rural) (Table 1).

In logistic regression model, males (OR 1.7, 95% CI 1.1–2.6), those having had a university education (OR 2.4, 95% CI 1.5–3.8), employed (OR 2.7, 95% CI 1.6– 4.4) and students (OR 6.9, 95% CI 2.5–19.2) were found to be predictive of previous training in CPR.

Fourteen percent (n=28) of trained respondents received their last training less than 6 months before the survey, 10% (21) were trained 6–12 months ago, 18% (36) 1–5 years ago, 54% (110) more than 5 years ago, and 4% (9) were unable to recall time of their last training.

Figure 1 shows the distribution of previous trainings depending on the type.


Forty four percent (n=89) of trained respondents attended one CPR course, 22% (46) attended two courses, 20% (41) 3–5 courses, and 11% (22) attended more than 5 courses. The remainder of the respondents (3%) reported forms of training, other than a course (internet, videos, books, etc.).

Forty seven percent (180/384) of respondents had no previous CPR training. The most common reasons for not taking CPR training were that the respondent never thought about the need to go for training (51%) or did not know where to attend the training (28%). About 10% reported they have always thought they have no need of CPR training. Reluctance to spend money or time was less common (1.4% and 4.6%, respectively). Occasional voluntarily reported reasons for not being trained in CPR ("other", 5.5%) included "training not offered", "no favourable opportunity", "fear" and "reluctance to study".


CPR knowledge

Self-perceived respondents' CPR knowledge was reported as follows: "absent" – 17.7% (68/384), "poor" – 45.6% (175), "moderate" – 29.7% (114), "good" – 5.5% (21), "very good" – 1.6% (6).

There was a strong relationship between the selfperceived knowledge level and previous training status: those who rated their knowledge as "moderate" and above were mostly previously trained (Table 1). With that, there was no association of self-perceived CPR knowledge level with the number of attended CPR courses, the time of last training or willingness to attend CPR training (P>0.05).

Almost half of the respondents (46%) correctly indicated site for chest compressions as lower half of the sternum in the middle of the chest, whereas more than 38% respondents selected left side of the chest. Among those who provided correct answer, 66% were previously trained in CPR. Correct answering was associated with previous CPR training, higher level of self-perceived CPR knowledge (excepting "very good" knowledge group, where only one out of 6 answered correctly), lower age and medical education, but independent from the number of attended courses, timing of last training, or other demographic characteristics (P>0.05) (Table 2).


Only 14 out of 384 respondents (3.6%) specified the rate of chest compressions in compliance with the currently recommended range of 100–120 per minute.[10] Correct answering to this question was associated with previous CPR training, higher level of self-perceived CPR knowledge (except in the "very good" knowledge group, where null out of 6 answered correctly), medical education and higher monthly income, but independent of the number of attended courses, timing of last training, or other demographics (P>0.05) (Table 2).

Among the healthcare professionals, 68% and 14% provided correct answers as of hand placement and rate for chest compressions, respectively.


Attitude and willingness to attend CPR training

Fifty two percent (201 of 384) respondents provided an affirmative answer to the question of whether or not they wish to attend CPR training, 31% had no interest in training, and 17% were unsure of their willingness.


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