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Abstract
Background Bystander response, including cardiopulmonary resuscitation (CPR), is critical to out-of-hospital cardiac arrest (OHCA) survival. Nearly 30% of Australian residents were born overseas, and little is known about their preparedness to perform CPR. In this mixed-methods study, we examined rates of training and willingness and barriers to performing CPR among immigrants in Australia.
Methods First, we surveyed residents in New South Wales, Australia, using purposeful sampling to enrich immigrant populations. Multivariate logistic regression was used to examine the association between place of birth and willingness to perform CPR. Next, we conducted focus-group discussions with members of the region’s largest migrant groups to explore barriers and relevant societal or cultural factors.
Results Of the 1267 survey participants (average age 49.6 years, 52% female), 60% were born outside Australia, most in Asia and 73% had lived in Australia for more than 10 years. Higher rates of previous CPR training were reported among Australian-born participants compared with South Asian-born and East Asian-born (77%, 35%, 48%, respectively, p <0.001). In adjusted models, the odds of willingness to perform CPR on a stranger were significantly lower among migrants than Australian-born (adjusted OR: 0.64; 95% CI 0.49 to 0.83); however, this association was mediated by history of training. Themes emerging from the focus-group discussions included concerns about causing harm, fear of liability, and birthplace-specific social and cultural barriers.
Conclusions Targeted awareness and training interventions, which address common and culture-specific barriers to response and improved access to training, may improve confidence and willingness to respond to OHCA in multi-ethnic communities.
- PUBLIC HEALTH
- CARDIOLOGY
- EPIDEMIOLOGY
- Out-of-Hospital Cardiac Arrest
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
Our mixed-methods approach advanced our understanding of attitudes toward training and willingness to engage in basic life support with under-researched multi-ethnic communities in New South Wales, Australia.
A range of approaches were used to recruit participants residing in these communities, with purposive sampling integrated to ensure diversity based on country of birth and to allow for comparisons with predominant migrant groups.
All measures-including participants’ knowledge, confidence and training history-were obtained using self-report.
Focus group discussions were facilitated by bilingual researchers in the participants’ language of preference.
Mediation analyses were used to explain the role of previous training in the association between birthplace and willingness to respond to out-of-hospital cardiac arrest.
Background
Out-of-hospital cardiac arrest (OHCA) is associated with poor survival.1 Prompt bystander response to OHCA more than doubles survival and optimises neurological outcomes.2 3 Common barriers to response include fear of causing harm, being sued, lack of knowledge and training, and concerns about not performing properly.4–7 Previous basic life support (BLS) training has been shown to be a significant factor in confidence and willingness to provide cardiopulmonary resuscitation (CPR) or use an automated external defibrillator (AED).8 Increasing the number of trained and willing responders in the community is important to optimise response,9 and an important group with low rates of BLS training are immigrants.10 11
Lower training among immigrants has been reported in developed countries despite widespread BLS training.12–14 For example, in Australia, first-aid and CPR training organisations are well established and programmes are widely available.15 16 Yet, an Australian-wide survey reported only 56% had previously undertaken CPR training, with lower rates among overseas-born participants.10 Despite this difference, there is little understanding of why this occurs and how this might be improved in migrant population groups.12 17
The specific aims of this study were: 1) to compare training and attitudes to BLS between predominant immigrant minorities and Australian-born residents; 2) to examine the relationship between immigrants’ birthplace and willingness to perform CPR and 3) to examine factors related to willingness and training uptake among some predominant immigrant minorities in Australia. Such information is important and will inform public health interventions in the future.12 17–21
Methods
Design
A mixed-methods research design was used to provide a comprehensive understanding of the topic, with data sources composed of surveys followed by focus-group discussions.
Surveys
Setting, sampling and participants
In Australia, over 7.5 million residents (29%) are born overseas.22 People born in India and China are the leading minority groups among non-English speaking migrants to Australia, with several other Asian countries (i.e., Vietnam, Philippines, Malaysia, Sri Lanka) among the top 10.23 A purposive sampling approach was taken to ensure sampling from migrants and allow comparison of individuals from some of the larger Asian immigrant communities with Australian-born participants. Based on previous literature, we estimate training rates of about 30% in these migrant groups.10 12 14 To enable comparison of rates of outcome variables we would need approximately ~300 per comparison group to obtain a CI width (precision) of ~10 points. Our study has 80% power to detect a 10% difference in rates between major migrant and Australian-born subgroups.
The survey occurred between May 2021 and May 2022 and 95% of participants completed it electronically and the remaining 5% on paper. Most participants were recruited through the FirstCPR study (89%), and surveys were filled at baseline prior to the FirstCPR intervention implementation. The FirstCPR study is a cluster randomised trial that aims to increase CPR education, training, and awareness in communities across New South Wales, Australia.24 Surveys were collected from 72 community organisations (social organisations, faith-based groups, sports groups) participating in FirstCPR and the majority of organisations were based in Western Sydney where 47% of residents were born overseas and 50% report speaking a language other than English at home.23 Response rate at FirstCPR participating community organisations was low (median response rate = 5%; range = 0.2%–35% of all members emailed surveys by their organisations). To augment participation by immigrant communities, an additional reach-out was conducted via targeted advertising on social media and by leveraging social networks. The survey contained 21 items including demographic information and questions on training, confidence and willingness to respond to a cardiac arrest emergency (online supplemental file 1A). Surveys were made available in English and three other commonly spoken languages (Arabic, Simplified Chinese and Vietnamese).
Supplemental material
Survey outcome measures
The primary outcome of interest was willingness to perform CPR on a stranger. We also examined secondary outcomes of willingness to use an AED on a stranger when one is available, and willingness to perform CPR and use an AED on friends and family. The primary outcome was categorised into a binary variable and defined as present if participants reported ‘Probably yes’ or ‘Definitely yes’ on a 5-point Likert scale. A similar categorisation was applied for willingness to use an AED. Participants could select reasons to explain why they were reluctant to respond from a list of multiple-choice options and any free-text responses were coded into categories. These reasons were further explored in the qualitative investigation. Country/region of birth (henceforth referred to as birthplace), as a main exposure of interest, was categorised into the major subgroups of Australia (40%), South Asia (26%), East Asia (20%) and other countries/regions (14%) which included a heterogenous group of English-speaking and non-English speaking nations.
Analysis
Analyses of survey data were conducted using R software, V.4.1.25 Descriptive statistics were calculated as means and proportions, with comparisons of mean measures conducted via t-tests, and comparisons of proportions via χ2 tests. Logistic regression models were developed to assess associations between birthplace and previous training, confidence and willingness to perform CPR and use an AED, specifically drawing comparisons between participants born in Asia (mainly South and East) and Australia. Statistical significance was set at p <0.05. Analysis was adjusted for age, gender, current work status, occupation/industry of those in the workforce, and self-rated overall health.26 27 To explore whether the relationship between birthplace and willingness to perform CPR was explained by previous training, we conducted mediation analyses using the zMediation test.28 Mediation analysis tests whether an association between two variables can be explained by an intervening variable on the causal pathway.
Focus group discussions
Participants
To examine barriers and enablers to training uptake and attitudes to BLS, focus group discussions were conducted between April and June 2022 with community members from select large migrant groups in New South Wales (mainly from India, China and Vietnam). Participants were eligible if they were over 18 years of age, first-generation immigrants, had not been to school in Australia, and had not accessed CPR training in the last five years. Participants were encouraged to discuss issues relevant to the research topic by asking open-ended questions (online supplemental file 1B). Discussions lasted about 1.5 hours each and were facilitated by bilingual researchers. SMunot facilitated two in-person groups in Hindi and English; the remaining researchers facilitated their groups virtually using the secure cloud-based videoconferencing service Zoom: QMD and LN facilitated one Vietnamese group each and GY facilitated two groups in Mandarin).29 30 Discussions were recorded, translated and transcribed verbatim into English.
Analysis
For analysis of qualitative focus group data, researchers independently read and coded the transcripts of the groups they facilitated (QMD, LN, GY), and SMunot coded all six. ZR paired up with SMunot to code transcripts of discussions from the two South Asian groups. SMunot then individually met with each team member to discuss, compare and arrive at consensus codes. When a decision could not be made, these were referred to a senior researcher (CC/JR/JB) and discussed until agreement was reached. Categories and themes included a combination of deductive and inductive thematic analyses.31 Thematic saturation was reached in six groups. Findings were analysed and synthesised using NVivo.32 Themes were organised using the COM-B theoretical framework that describes: Capability (C), Opportunity (O), and Motivation (M) to perform the desired Behaviour (B)33 (figure 1).
Mapping of themes using the Capability (C), Opportunity (O), Motivation (M) to perform the desired Behaviour (B) framework. #Definitions for Capability, Reflexive Motivation and Automated Motivation have been adapted from Michie et al.33 AED, automated external defibrillator; CPR, cardiopulmonary resuscitation.
Patient and public involvement
The public or members of the community were involved in the design of the survey used to collect the data for this study. The initial survey questions were pilot-tested with members of the public who represented the target study population. They were also asked to comment on the time required to complete the survey. Their suggestions and feedback were incorporated when finalising the survey questionnaire. Committee members at social and sports organisations participating in the FirstCPR study where the survey was administered were closely involved in facilitating the implementation of the intervention at their organisations.
Results
Survey participants
There were 1267 survey participants, with a mean age 49.6 years (SD: 15.8) and 52% female (table 1). Most surveys were completed in English (n=1142 or 90%). A smaller proportion was completed in one of the other languages available: Simplified Chinese (n=102 or 8%), Arabic (n=12 or 1%), and Vietnamese (n=6 or 0.5%). However, only 61% reported that English was their main language at home. The majority of participants (60%) were born outside Australia (in a total of 56 countries), with 44% of these from countries in South Asia and 33% from countries in East and Southeast Asia (henceforth referred to as East Asia). More than 60% of participants had completed a degree, diploma or postgraduate education. Immigrant participants had lived in Australia for a median of 16 years (range: 0.1–72) and most (73%) for more than 10 years.
Participant sociodemographic characteristics, awareness, training and attitudes related to CPR and AED use
Awareness, training and attitudes to BLS: including CPR and AED use
Knowledge of CPR and AEDs was generally poor and lower among participants born in South Asia and East Asia compared with those born in Australia and other countries (table 1). A significantly greater proportion of Australian-born participants had obtained CPR training compared with those born in South Asia or East Asia (77% vs 35% and 48%, respectively). Training was most commonly obtained for job requirements (online supplemental file 1: table S1). The most common reasons for not accessing training included ‘never thought about it’ and ‘did not know where to go to learn’ (online supplemental file 1: table S1). These reasons were more frequently reported among participants born outside Australia (p <0.001) (online supplemental file 1: figure S1).
Both confidence and willingness to perform CPR and use an AED were higher among Australia-born participants (table 1). A greater proportion of participants indicated willingness to perform CPR or use an AED on family and friends as compared with willingness to respond to strangers. This was true for all groups, irrespective of their country of birth. Reasons for reluctance to perform CPR or use an AED were mainly due to lack of knowledge and confidence, as well as concerns about causing harm (online supplemental file 1: tables S2 and S3). We examined the relationship between participants’ level of education and knowledge-related responses and found no association with education level (online supplemental file 2: table S4).
Factors associated with the attitudes to perform CPR or use AEDs
In univariate analyses, South/East Asian birthplace, older age, female gender, working in an industry where first-aid training was uncommon, not working or being retired, and reporting poor general health were associated with lower odds of prior CPR training, confidence in BLS response, and willingness in BLS (online supplemental file 2: tables S5–S7). We found no association between level of education and prior training, confidence, or willingness to perform CPR or use an AED (online supplemental file 2: tables S5–S7). In multivariate models, after adjusting for age, gender, overall health and occupation status, Asian birthplace was significantly associated with lower willingness to perform CPR on a stranger, and to use an AED (table 2; online supplemental file 2: figure S2).
Multivariate (adjusted) models of the association between birthplace and willingness to perform CPR/use an AED
Birthplace was correlated with previous training. In multivariate models, we examined for interaction between birthplace and prior training and found no significant interaction (p =0.539). Mediation analysis found that the relationship between birthplace and willingness was partially mediated (47%) by prior training, indicating a substantial indirect effect between birthplace and willingness (online supplemental file 3: figures S3 and S4).
Focus group participants
Focus group participants (n=38, i.e., five to eight per group) were first-generation immigrants (40% from South Asia, primarily India, and 60% from East Asia, mainly China and Vietnam). Participants’ ages ranged from 19 to 77 years; 45% were male; and 50% were working or self-employed. Three-quarters had never accessed any CPR training, and of the remaining, one participant had completed training in the last 5 years (online supplemental file 4: table S8).
Themes emerging from focus group discussions
Figure 1 depicts the themes organised using the COM-B framework developed by Michie et al.33 Common barriers included limited access and opportunities to train; limited knowledge; and reluctance to respond due to poor knowledge, fear of causing harm, and fear of legal consequences. Societal and cultural factors influencing participants’ attitudes to training uptake and their willingness to respond allowed for further understanding of additional barriers that may be more specific to some population subgroups (table 3; online supplemental file 4: table S9 details selected supporting participant quotes).
Themes that emerged from focus group discussions with multiethnic community members
Awareness, training opportunities
The key theme of ‘awareness and training’ (Capability) comprised subthemes related to the lack of opportunity to access training that was equivocally discussed by participants. While there was some recollection of first-aid training at schools, there was often no opportunity afforded for practical skills training given large class sizes. Movies and television were often identified as knowledge sources for CPR or AEDs. Knowledge of CPR was superficial and limited to an overall understanding that it involved pressing on the chest. Awareness of AEDs was much lower. Participants expressed uncertainty with respect to ability to recognise if a person was in cardiac arrest.
“First of all, I won’t even know how to identify if this person needs CPR or something else (three other participants nodded in agreement).” — P1, 45-50 year-old male from India
Societal and cultural influences in attitudes to training and response in emergencies
Previous experiences, societal, and cultural influences shape current attitudes
Participants stated that a country’s culture informs awareness and attention to safety, first-aid and emergency response. Some discussed coming from an environment with general caution and fear in approaching strangers or helping in the event of an emergency, often citing stories of trouble with authorities. Furthermore, a lack of structured emergency response systems in some countries was noted as contributing to poor awareness and potentially influencing attitudes toward emergencies. There were several recollections of emergency response in their country of origin, where most patients would be taken to a nearby hospital, or bystanders would wait for someone medically trained to respond without attempting resuscitation. A few older adults believed they would ‘somehow manage’ by seeking help from neighbours or other bystanders.
“Somehow in India… somehow people manage to get help from people around/neighbours [sic]. People believe that someone around will somehow help—we can call someone—or call the doctor/family doctor quickly.” — P9, 65–-70 year-old female, from India
Poor attention to safety, low risk perception, denial of the possibility that things can go wrong
A nonchalant attitude toward safety issues in their home countries stood in stark contrast to countries such as Australia, which place considerably more importance on preparation and preventive measures. Some participants from India particularly recalled the societal inequities and disregard for the safety of those from lower socioeconomic strata. Similarly, some commented that learning to swim was a luxury in their hometowns, whereas it is common in Australia, along with other water-safety measures. Participants from Vietnam noted that a sense of complacency around water was commonplace, despite drowning-related deaths.
“I also want to add the word ‘complacency’ … I think that besides the lack of knowledge, people are also complacent, like ‘We’ll be ok’, or ‘People around me will also be ok’.” — P26, 20-25 year-old female, from Vietnam
Culturally, there may be discomfort with acknowledging that ‘something may go wrong’.
“I mean you know you just don’t think it’s important [ that something bad can happen ] you actually can’t say that … you will actually be laughed at if you say that [we should take life-jackets] … they will say ‘eh kuch nahi hota hain’ [meaning ‘ nothing’s going to happen’].” — P1, 45-50 year-old male, from India
Participants from India also noted a tendency to believe in karma and that there is little one can do to stop what is written in a person’s fate.
“We believe too much in karma—because there is no option … what is meant to happen will happen anyway, so you don’t have much of an option in that sequence.” — P1, 45-50 year-old male, from India
Willingness to respond
‘Willingness to respond’ identified as a main theme (Reflective Motivation) includes the factors that influence willingness — including participants’ perceptions of what CPR or AED use entails. Participants discussed CPR as a complex, tiring activity that is best left to those who are trained.
“If they are on the road and see someone collapsing, the first thought would be calling the ambulance and they would not dare to perform resuscitation for that person. Only if the witnessing person is a nurse or doctor, he or she would resuscitate that person.” — P23, 40-45 year-old male, from Vietnam
However, most participants were willing or had the desire to help and do whatever they could in the event of an emergency to save a life. There was less reluctance to respond if the patient was a family member (as this was seen as their responsibility and duty), compared with strangers. This reluctance was related to the fear of causing harm or doing something incorrectly.
“Family/friend or someone you know—you still feel that ‘comfortness’, you know and the urgency that you have to save. But for a stranger, the whole responsibility you know, if something goes wrong … I don’t know in Australia if we are allowed to go and start doing CPR on an unconscious person before calling the emergency or police.” — P3, 40-45 year-old female, from India
Lack of training (or recent training) made participants feel unqualified to respond to such a serious emergency. With respect to AEDs, participants were concerned that the electric current may travel to other organs and cause more harm if used incorrectly. Fear of legal implications of using an AED was another key reason that was mentioned by several participants.
Contextual factors related to response
Personality traits and innate ability to respond in stressful situations came up as factors that would influence a person’s actions in the event of an emergency. Other contextual factors discussed included the dynamics of responding in the presence of a crowd. There was the recollection of a stand-and-watch approach (bystander effect) or waiting for someone else to take the initiative to respond.
“If people gather, people will take photos, videos … but until and unless someone is actually taking the initiative to go and help … other people may not … once someone will take the initiative then others will come.” — P3, 40-45 years female, from India
However, it was noted that the reverse has been observed for emergencies where a person may be conscious, with bystanders showing keenness to help irrespective of correct first-aid knowledge. Participants indicated that it may be easier to feel comfortable helping in a non-life-threatening incident, such as a broken leg, versus an unconscious or drowning person. Systemic features such as the availability of a standardised emergency response system differ across countries and were seen to play an important role in the motivation to act. Patient characteristics, including gender, and disagreeable features (eg, presence of blood or additional injuries) were mentioned as potential barriers to response.
“Because people may be a bit reluctant if the victim is a teenage girl but will be less reluctant if the victim is a male … I personally don’t have any problems (with the sex difference). I only worry about the hygiene, for example, if it’s too dirty I may not want to do it [CPR].” — P37, 40-45 year-old female, from China
The majority of participants expressed willingness to follow emergency call-takers’ instructions during an emergency; however, there was discussion of communication barriers including language, accent and speed of speech as possible impediments to following instructions. By the end of the discussion, there was positive intent to register as a volunteer community responder, but only after obtaining formal training and feeling confident enough to respond.
“If we can learn something new and we can help someone—we would definitely do it.” — P15, 50-55 year-old female, from India
“I think this app is good! … but I’m not sure if people are willing or not. Sometimes we may not have the willing (to help)[sic]. Sometimes, if we are busy and see that someone like that (in cardiac arrest), we may feel guilty. I (would) rather not knowing a person is in cardiac arrest than knowing and not coming to help, I would feel very guilty.” — P28, 45-50 year-old female, from Vietnam
Participants identified such previous experiences and societal values as shaping current attitudes and concerns and noted the importance of addressing these in training programmes.
Willingness to train
Participants unanimously agreed that the brief five-minute demo video played toward the end of the discussion explained the steps of response clearly, simplified it, and sparked interest in learning more. It instilled some confidence and allayed some concerns. However, participants expressed the belief that practical, hands-on training was necessary to understand the techniques better and feel confident enough to respond to an emergency.
“… but just watching that movie, I think it may be a bit limited if it can be used [sic] because it mentioned something at a hands-on level … it is impossible that you know how to do CPR right after watching the video clip.” — P37, 40-45 year-old female, from China
Participants had not come across such educational material previously and there was no awareness as to where they could find similar videos. There was agreement that such short educational videos would be well received and acceptable within their communities and that they should be on display in public spaces such as malls to increase awareness within the community. Participants also expressed wanting to learn more about AEDs and to find where these were located. Participants were aware of AEDs being locked away for fear of being stolen and noted the value of having devices more accessible for the community. There was a recognition that it would feel good to be able to help someone in an emergency and participants stated no issue with shaving chest hair or cutting clothes in preparation for using the device.
Enablers to facilitate training and uptake in the community
Most saw value in investing in education campaigns. Televising brief videos at doctors’ waiting rooms and railway platforms was also suggested. Repeated messaging that was attention-grabbing and did not demand too much time was seen as a good way to increase awareness. Participants discussed that training for immigrants needs to be more targeted, addressing previously held cultural and societal beliefs and influences that may be barriers to responding to cardiac-arrest emergencies. To this end, they discussed the importance of training being conducted in the language of preference, while also noting that it would be useful to also learn English jargon words that are likely to be used by paramedics or emergency call-takers in the event of an emergency.
In addition to training, they expressed a preference for the government to convey messages and increase awareness that it is safe to respond and to clarify that individuals would not be legally liable for any harm. An atmosphere of assurance was regarded as necessary to encourage the willingness to respond. Participants were even less familiar with using an AED, but after the discussion and viewing the demo video, the overall perception of AEDs was that they seemed simple, convenient and easy to use. Suggestions were made for AEDs to be made more widely available and accompanied by regular awareness campaigns and other approaches that address the full suite of identified barriers.
Participants felt educational messages conveyed from a young age have a significant impact on the societal and cultural values related to emergency response, noting that if the community value of ‘helping’ is not addressed, then training is likely to be tokenistic and not necessarily increase response. Several other suggestions made to increase training uptake have been noted in box 1.
Suggestions to facilitate training uptake in the community, particularly including diverse communities
Where and when
Widespread and targeted delivery to reach diverse population subgroups
in their daily environment (for example, schools, workplaces)
in places where they congregate for other reasons, such as community organisations, temples, churches
in sports clubs especially given that several are likely to have an AED on-site
in public places (for example, shopping centres, libraries) - to reach those who are out of the workforce
in childcare centres to reach stay-at-home parents
at community events to reach diverse groups
upon migration into the country
What and how
Increasing public awareness in communities is an important precursor to motivate training uptake
regular, repeated public health messaging to increase awareness
training laypeople seen as a government responsibility
importance of public health messaging for assurance and to allay concerns related to fear of liability, especially among immigrants
promotion of training via trusted members of the community and in culturally sensitive ways
access to training or refreshers important
tailored training to address the ingrained social and cultural beliefs of those being trained
consider making training mandatory or incentivise, as there may be less motivation to take it up voluntarily
acknowledging that training may inherently seem boring and need creative and structured approaches to increase uptake
involving children could be a good strategy to encourage and engage parents to take part in training
Customised marketing
consider gamifying training for a younger audience
use bilingual newspapers and popular apps, social media channels and community webpages—for broad-based reach to diverse communities
suggestions were made to capitalise on the familiarity and accessibility of the Service NSW app and to integrate CPR videos into the app
Address practical barriers
free training likely to encourage widespread uptake
suggested duration: 30 min to 2 hours
language of delivery: bilingual
proximity: training sessions should be easy to access
Note: Quotes that represent participant suggestions can be found in online supplemental file 4: table S10.
AED, automated external defibrillator; CPR, cardiopulmonary resuscitation.
Discussion
Our results indicate suboptimal rates of training, willingness and confidence in performing CPR and using AEDs among study participants residing in Australia, particularly among migrants. Participants’ birthplace was significantly associated with willingness, even after controlling for key sociodemographic variables, but this relationship was substantially mediated by prior training. Despite high levels of education among Australian migrants, lack of previous training in CPR, and opportunity to train, as well as concerns about legal ramifications, societal and cultural perceptions, fear of causing harm, and perceived lack of sufficient expertise were identified as barriers. In our study, level of education was not associated with self-rated CPR or AED knowledge, confidence, or willingness to respond to OHCA. The limited knowledge among migrants from Asia is notable given that a substantial proportion of these participants had lived in Australia for more than ten years, reflecting low awareness and training opportunities in countries of origin, but also in Australia. This suggests that awareness-raising and provision of training in CPR and AED use may reduce this gap but focus group discussions highlight that customisation is necessary. CPR is perceived as a complex skill and many participants express a preference for someone trained to provide it, rather than trying to attempt it themselves. Participants suggested their concerns could be comprehensively addressed via training and public health messaging to create an atmosphere of assurance for lay responders to OHCA.
Barriers of limited opportunities to train — as well as reluctance to respond due to poor knowledge, fear of causing harm, and fear of legal consequences — have been identified in several other studies.4–7 34–38 Most other studies exploring CPR knowledge and willingness among migrant, minority or disadvantaged population groups are from the USA, where a different context for migrant groups and experiences are reported.13 39–42 A qualitative investigation in Latino neighbourhoods in Denver, Colorado, found immigration status, language, racism and fear of touching someone they did not know, or touching a female, were among the cultural barriers identified that could prevent someone from performing CPR.34 Other studies have identified legal implications, concerns of causing harm, the home country’s cultural norms and attention to safety, first-aid, and emergency response contributed to attitudes towards BLS.43–45 Studies among Chinese immigrants living in the USA identified that CPR knowledge and training were poor, and the possibility of liability was one of the barriers to learning CPR.13 Country-specific laws and the overall social environment may influence willingness, as noted in previous research conducted in China and India with poor protection laws35 46 and among minority groups in nations where protective ‘good Samaritan laws’ have existed for a long time.34 37
We are unaware of studies that have explored these attitudes in-depth among migrant groups living in Australia, and only a few studies internationally have examined preparedness to respond to OHCA among some migrant communities.37 47 Our qualitative findings highlighted that although most participants would call for help in an emergency, some older adults (over 60 years) noted not knowing the local emergency number or emergency response system. Given previous experiences in nations where the most common response to an emergency was to rush directly to the nearest hospital,48 some participants considered driving to the hospital rather than calling an ambulance, or calling a relative or other known person with medical knowledge as an initial reaction, but several also mentioned contacting the emergency-response system. In addition to describing limited access to training opportunities in their countries of origin, migrants stated that they had not considered pursuing training in Australia and that they did not know where to pursue such training. These barriers were echoed in the HeartWatch cross-sectional study among Australians.10 Furthermore, differences in health services and variable emergency response systems in countries of origin may influence migrants’ perceptions of how systems function in Australia. Therefore, these groups could benefit from a targeted training programme that also factors in the familiarisation to the emergency-response system.49
Other notable societal influences may limit motivation to access training or prepare for emergencies such as cardiac arrest. Focus group participants from Indian and Vietnamese backgrounds discussed the relatively nonchalant attitudes to safety and preventive measures in their home countries, and that an attitude of denial or discomfort about acknowledging that things could go wrong was prevalent in their communities. An education campaign that explicitly states that most cardiac arrests occur at home, and can happen to anyone without much warning, may help overcome these attitudes and motivate people to be prepared.
Another barrier that migrants from countries with low English proficiency may face is the struggle to find CPR training provided in a language of their choice.7 17 37 A Swedish study reported that migrants, elderly people and those not included in the workforce were less likely to have accessed recent training.11 Our findings echo these, providing more details of the reasons why they do not access training, and supporting calls to augment current training opportunities by addressing barriers such as language, cost and easy accessibility with respect to the convenience of time and location. It is also noteworthy that the majority of elderly people just want to learn the practical component and do not feel the need for certification. Targeted strategies to increase opportunities for laypeople to get ‘hands on a manikin’ and practice using a dummy AED are additional considerations to increase community-wide confidence and willingness to respond.
Our study has some limitations. Although we endeavoured to maximise sampling variability by using a wide range of recruitment approaches, our non-random survey sample restricted generalisability. The high non-response rate could also have biased the sample toward individuals with more positive attitudes overall and may overestimate population-wide training and willingness to perform CPR. We did enrich our sample with many participants from the larger migrant groups, but had an inadequate sample to look comprehensively at all distinct migrant groups. The similarity in our findings across the studied migrant subgroups suggest our findings may be generalisable to other non-English speaking migrant groups. Involving recruitment staff that reflect the diversity of the study population could potentially result in more successful engagement with other migrant groups.
Conclusions
Using a mixed-methods approach, this study identified gaps in training and willingness to respond to cardiac-arrest emergencies in a multi-ethnic community. Differences between Australian-born and Asian-born migrant participants were significant. When designing training programmes and public health messaging, understanding commonly held barriers as well as specific societal and cultural factors that influence attitudes are equally important. Targeted strategies to increase awareness using codesigned and customised marketing; using multi-media channels, including social media or in-person venues; and programmes that include a ‘hands-on’ CPR and AEDs that are accessible (in terms of cost, location, and availability in language of preference) may lead to increased uptake that will subsequently result in greater bystander awareness and more positive attitudes to providing response.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and ethics approval was obtained from the University of Sydney Human Research Ethics Committee (#2020/537 and #2021/968). The majority (95%) of survey participants provided informed consent electronically by clicking on the study link and the remaining provided consent on paper. Focus group participants provided initial verbal consent over the phone followed by electronic or paper consent. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
As part of the National Health and Medical Research Council (NHMRC) partnership project grant, the study received support from the following partner organisations: NSW Ministry of Health, Surf Life Saving NSW, Western Sydney Local Health District, NSW Ambulance, The National Heart Foundation of Australia, Michael Hughes Foundation (recently merged and operating as Heart of the Nation), Heart Support Australia, City of Parramatta, Take Heart Australia and the NSW Data Analytics Centre. The authors would also like to acknowledge Ambulance Victoria for permission to use their educational material, the technical assistance of Cameron Fong of the Sydney Informatics Hub, at the University of Sydney and the statistical assistance of Haeri Min.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
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Footnotes
Twitter @SonaliMunot, @Scientosis, @clara_chow
Contributors CC conceived the initial FirstCPR study design and drafted the first protocol submitted to the NHMRC with contributions from other listed coauthors (JB, JR, AB, SMarschner, AC, CS, PMM, GJ, BA, SK, PK). SMunot managed the project and designed the FirstCPR survey in consultation with CC, JB, JR, AB, SMarschner, AC, CS, PMM, GJ, and BA. SMunot drafted the protocol related to this mixed methods investigation, obtained ethics approval, and drafted the current manuscript in consultation with CC, EJR, JB, JR and AB. SMunot analysed the survey data in consultation with CC, EJR and SMarschner. SMunot, GY, LN, and QMD facilitated the six focus group discussions and transcribed, coded, analysed, and interpreted the findings with support from ZR. SMunot, CC, EJR, JB, JR, GY, LN, AB, and QMD, ZR, SMarschner, AC, CS, PMM, GJ, BA, SK, and PK reviewed and provided scientific input on several manuscript drafts and approved the final submission. CC is the overall guarantor.
Funding This work was supported by the National Health and Medical Research Council (NHMRC) of Australia partnership project grant (#1168950). SMunot was funded by PhD scholarships from The University of Sydney centres (Westmead Applied Research Centre and Charles Perkins Centre Westmead), JB is funded by a Heart Foundation of Australia Fellowship (##104751), JR is funded by an NHMRC Investigator Grant (GNT1143538), and CS is funded by an NHMRC Practitioner Fellowship (#1154992) and NSW Health.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
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