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Victims of out-of-hospital cardiac arrest (OHCA) have higher survival rates and more favorable neurological outcomes when basic life support (BLS) maneuvers are initiated quickly after collapse. Although more than half of OHCAs are witnessed, BLS is infrequently provided, thereby worsening the survival and neurological prognoses of OHCA victims. According to the theory of planned behavior, the probability of executing an action is strongly linked to the intention of performing it. This intention is determined by three distinct dimensions: attitude, subjective normative beliefs, and control beliefs. We hypothesized that there could be a decrease in one or more of these dimensions even shortly after the last BLS training session.
The aim of this study was to measure the variation of the three dimensions of the intention to perform resuscitation according to the time elapsed since the last first-aid course.
Between January and April 2019, the two largest companies delivering first-aid courses in the region of Geneva, Switzerland sent invitation emails on our behalf to people who had followed a first-aid course between January 2014 and December 2018. Participants were asked to answer a set of 17 psychometric questions based on a 4-point Likert scale (“I don’t agree,” “I partially agree,” “I agree,” and “I totally agree”) designed to assess the three dimensions of the intention to perform resuscitation. The primary outcome was the difference in each of these dimensions between participants who had followed a first-aid course less than 6 months before taking the questionnaire and those who took the questionnaire more than 6 months and up to 5 years after following such a course. Secondary outcomes were the change in each dimension using cutoffs at 1 year and 2 years, and the change regarding each individual question using cutoffs at 6 months, 1 year, and 2 years. Univariate and multivariable linear regression were used for analyses.
A total of 204 surveys (76%) were analyzed. After adjustment, control beliefs was the only dimension that was significantly lower in participants who took the questionnaire more than 6 months after their last BLS course (
Control beliefs already show a significant decrease 6 months after the last first-aid course. Short interventions should be designed to restore this dimension to its immediate postcourse state. This could enhance the provision of BLS maneuvers in cases of OHCA.
Survival after out-of-hospital cardiac arrest (OHCA) is estimated at around 10% in Europe, with recent studies showing marked differences between regions [
According to the theory of planned behavior, the probability of executing an action is strongly linked to the intention of performing it [
In Switzerland, the rates of successful OHCA resuscitation vary from 10% to 17% [
The aim of this study was to measure the variation of the three dimensions of the intention to perform CPR according to the time elapsed since the last first-aid course. Identification of any significant difference could potentially help to design specific interventions and hopefully improve the rate of bystander-initiated resuscitation.
This was a closed web-based questionnaire study following the CHERRIES [
The two largest companies providing first-aid courses in Geneva (Association Genevoise des Sections de Samaritains, a Red Cross–affiliated national society, and Firstmed, a privately owned company) were asked for a list of email addresses of former CPR course participants. To protect individual data, both societies refused to send us such a list directly but agreed to dispatch emails on behalf of the investigators. They were therefore provided with a generic text containing summarized information about the study along with the link to the online survey. Both companies were asked to send this email to participants who had followed a first-aid course between January 2014 and December 2018.
Emails were sent between January and April 2019. Although the exact number of sent and “bouncing” emails had been asked for, these data could not be gathered as one of the two companies experienced technical problems with their mailing system. Reminders could not be sent as per the request of both companies.
No financial incentive was given to participate in this study.
A website based on the Joomla! 3.9 content management system (Open Source Matters) was specifically designed for this study. The Community Surveys 5 component (CoreJoomla) was used to create the online survey and record the answers in an encrypted MariaDB 5.5.5 database (MariaDB Corporation AB) located on a Swiss server. As this was a closed study, and to ensure irreversible anonymization, we decided not to use either cookies or internet protocol address restrictions. A log search was nevertheless performed to identify potential duplicate entries.
The survey itself was displayed over 4 pages. The first 2 pages were designed to gather demographic data. The 17 questions were displayed over pages 3 and 4, which contained 9 and 8 questions, respectively. The system ensured that participants had answered all of the questions on a page before allowing them to move forward. All answers could be reviewed and changed as long as the survey was not finalized.
Upon loading, the website immediately displayed a summarized consent form and a confidentiality notice as well as a link to a detailed description of the study. A statement regarding data collection and storage was also shown, and the purpose and duration of the survey were detailed. Participants were informed that they could decide to leave the study at any time, and were given an email address they could use to contact the investigators. No personal data were collected.
A first set of general questions was created to gather demographic data, determine the time elapsed since the last CPR training course, and record information regarding the number of prior CPR courses followed. A set of 17 psychometric questions was then designed to assess each dimension of the intention to perform CPR (
The survey and the data extraction mechanism were thoroughly tested by all investigators prior to the launch of the study.
The primary outcome was the difference in each of the three dimensions of the intention to perform resuscitation between participants who had followed a first-aid course less than 6 months before taking the questionnaire and those who took the questionnaire more than 6 months and up to 5 years after following such a course. The investigators decided to use a 6-month cutoff since the alternative of asking lay people to attend an on-site refresher course so soon after the last training course would be unlikely. Nevertheless, offering a short, targeted, and portable intervention after this time span might be considered.
Secondary outcomes were the changes in each of the three dimensions using a 1-year and then a 2-year cutoff rather than the 6-month cutoff used to compute the primary outcome, and the change in each individual question using the 6-month, 1-year, and 2-year cutoffs.
Survey data were extracted to a comma-separated value file and imported in Stata 16.0 (Stata Corp LLC). Records were searched for potential duplicate entries as per our protocol. Health care professionals, students of health care professions, and participants who had not followed a CPR course during the previous 5 years were excluded. Incomplete surveys were also excluded.
Stata was used for statistical analysis. Numerical values (–1, –0.5, 0.5, and 1) were attributed to each of the 4 answers gathered through the use of Likert scales, with positive values assigned to the answers that were in favor of the intention to perform resuscitation. All survey questions carried the same weight and were summed by dimension. Univariate linear regression was used to assess the variation of each specific dimension of the intention to perform resuscitation according to the time elapsed since the last first aid course. A multivariable linear regression model was used to identify the effect training centers or age groups might have had on these variations. A double-sided
The original dataset is available in the Mendeley Data repository [
Overall, 383 surveys were started, 270 (70.5%) of which were completed. A total of 204 of the completed surveys (75.6%) were analyzed after application of the exclusion criteria (
Characteristics of the participants, including the number of prior BLS courses, are described in
Participants who took the questionnaire more than 6 months after their last first-aid course had significantly lower scores regarding control beliefs and subjective normative beliefs (
Flowchart of the inclusion of former first-aid course participants (Geneva, Switzerland, 2019).
Characteristics of the former first-aid course participants included in the analysis (N=204).a
Characteristic | Last course followed ≤6 months before (n=85) | Last course followed >6 months before (n=119) | ||
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.045 | |
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Mandatory education | 3 (4) | 3 (2.5) |
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Professional diploma | 18 (21) | 34 (28.6) |
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Secondary education | 33 (39) | 22 (18.5) |
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High school | 8 (9) | 15 (12.6) |
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University | 21 (25) | 39 (32.8) |
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Other | 2 (2) | 6 (5.0) |
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.74 | |
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Single | 48 (56) | 63 (52.9) |
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In a relationship | 16 (19) | 29 (24.4) |
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Married | 21 (25) | 26 (21.8) |
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Widowed | 0 (0) | 1 (0.8) |
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<.001 | |
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<18 | 18 (21) | 3 (2.5) |
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18-25 | 32 (38) | 46 (38.7) |
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26-30 | 6 (7) | 10 (8.4) |
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31-35 | 5 (6) | 11 (9.2) |
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36-40 | 8 (9) | 3 (2.5) |
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41-45 | 1 (1) | 8 (6.7) |
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46-50 | 6 (7) | 15 (12.6) |
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51-55 | 6 (7) | 17 (14.3) |
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>55 | 3 (4) | 6 (5.0) |
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.09 | |
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Female | 66 (78) | 79 (66.4) |
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Male | 19 (22) | 40 (33.6) |
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.29 | |
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1 | 42 (49) | 59 (49.6) |
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2 | 15 (18) | 32 (26.9) |
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3 | 13 (15) | 11 (9.2) |
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≥4 | 15 (18) | 17 (14.3) |
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<.001 | |
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AGSSd | 43 (51) | 107 (89.9) |
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Firstmed | 35 (41) | 2 (1.7) |
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Other | 7 (8) | 10 (8.4) |
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aTotals may not equal 100% due to rounding.
b
cBLS: basic life support.
dAGSS: Association Genevoise des Sections de Samaritains.
Univariate analysis of the three dimensions of the intention to perform resuscitation in first-aid course participants (N=204).
Dimension and questionsa | Last course followed ≤6 months before, mean (95% CI) | Last course followed >6 months before, mean (95% CI) | |||||
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6.06 (5.68-6.45) | 6.06 (5.79-6.33) | .99 | ||||
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Thinking that performing resuscitation could save a life | 0.78 (0.70-0.87) | 0.80 (0.74-0.87) | .79 | |||
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Knowing the importance of starting a resuscitation before EMSb arrival | 0.91 (0.84-0.98) | 0.92 (0.86-0.97) | .93 | |||
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Not being afraid of disease transmission | 0.47 (0.33-0.62) | 0.66 (0.55-0.77) | .03 | |||
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Not being afraid of hurting the victim by performing CPRc | 0.91 (0.85-0.98) | 0.84 (0.77-0.91) | .14 | |||
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Not being afraid of worsening the victim’s condition | 0.69 (0.57-0.82) | 0.75 (0.68-0.83) | .41 | |||
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Not being afraid of legal action | 0.78 (0.67-0.88) | 0.59 (0.48-0.70) | .02 | |||
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Being proud of performing resuscitation successfully | 0.61 (0.48-0.74) | 0.58 (0.47-0.69) | .76 | |||
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Belief that knowing CPR is important for society | 0.91 (0.85-0.96) | 0.92 (0.89-0.96) | .59 | |||
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1.90 (1.61-2.19) | 1.45 (1.18-1.73) | .03 | ||||
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Belief that relatives would be proud if the participant performed resuscitation | 0.54 (0.42-0.67) | 0.57 (0.46-0.68) | .72 | |||
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Belief that relatives want the subject to resuscitate them if needed | 0.56 (0.43-0.70) | 0.45 (0.32-0.57) | .19 | |||
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Knowing that relatives are the most likely victim | 0.02 (–0.13-0.18) | –0.6 (–0.19-0.07) | .42 | |||
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Diffusion of responsibility | 0.77 (0.68-0.86) | 0.50 (0.38-0.62) | .001 | |||
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3.62 (3.31-3.93) | 2.18 (1.83-2.53) | <.001 | ||||
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Knowledge of the emergency number | 0.91 (0.85-0.96) | 0.70 (0.59-0.81) | .004 | |||
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Feeling able to resuscitate | 0.56 (0.45-0.67) | 0.16 (0.04-0.29) | <.001 | |||
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Feeling able to recognize a cardiac arrest | 0.68 (0.58-0.77) | 0.28 (0.17-0.39) | <.001 | |||
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Not believing that only health care professionals can adequately perform resuscitation | 0.77 (0.67-0.87) | 0.72 (0.64-0.81) | .46 | |||
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Knowing how to perform a resuscitation | 0.70 (0.61-0.79) | 0.31 (0.20-0.41) | <.001 |
aFor individual questions, scores can range from –1.0 to +1.0; a positive score indicates an answer in favor of the intention to perform resuscitation.
bEMS: emergency medical services.
cCPR: cardiopulmonary resuscitation.
The association between the time elapsed since the last BLS course and the fear of catching a disease while providing CPR disappeared after adjustment (
Fear of legal action was higher in participants who took the survey more than 6 months after having followed their last BLS course. The direction and the amplitude of this association did not change after adjustment (
Control beliefs, including knowledge of the emergency number to dial in case of cardiac arrest, already showed a significant decrease only 6 months after the last BLS course. Although some authors have advocated for a much shorter period than the recommended 2-year interval between BLS refresher courses given the need to freshen up CPR skills [
The participants who took the questionnaire less than 6 months after following their last BLS course were significantly younger and less likely to have been trained by the Red Cross–affiliated center. Although adjusting for these variables nullified the statistical significance initially found regarding subjective normative beliefs when the cutoff was set at 6 months, the change regarding this dimension was still significant after adjustment when the cutoff was set at 2 years. This effect was mostly related to the diffusion of responsibility element. Victims of the so-called bystander effect (ie, being less likely to help a victim when other people are present [
Although Vaillancourt et al [
Strangely enough, although the survey was conducted before the COVID-19 pandemic, participants who had followed a BLS course in the year preceding the survey were more afraid of disease transmission. As this study was not designed to investigate this unexpected finding, its cause is not easily determined but could be a difference in course contents. A change in the guidelines could hardly play a role in this result, as the study took place in 2019 with the last major guidelines issued in 2015 [
Of particular concern is the fact that more than half of the participants were unaware that the probability of performing CPR was higher on a relative than on a stranger. Whether this item belongs to control beliefs as suggested by Vaillancourt et al [
On a more positive note, the attitude and subjective normative beliefs dimensions were globally preserved even 2 years after the last BLS course. The fact that health care professionals are not the only people able to correctly perform CPR now seems to be well-recognized [
Although this study has some strengths such as the relatively high number of participants despite the absence of mail reminders and the absence of outcome assessment bias thanks to electronic data recording, some limitations must be acknowledged. Lack of email reminders might have led to selection bias, as the proportion of highly motivated participants might be higher in this setting. Indeed, the high proportion of participants who had followed 2 or more BLS courses is potentially concerning, particularly given the low rate of bystander-initiated CPR in the literature and the obligation of following a BLS course to obtain a driving license in Switzerland. Nevertheless, this might, if anything, have dampened the effect of the time elapsed since the last BLS course, and led to underestimation rather than overestimation. Another limitation is that, given the aforementioned technical issues, the actual participation rate could not be calculated as the number of sent and bouncing emails could not be obtained. Furthermore, we were unable to ascertain the actual number of first-aid course participants during the study period as both companies were either reluctant or unable to provide us with these figures. Had we been able to obtain these data, they would still have been questionable. Indeed, even though we specifically asked both training companies to send invitation emails only to participants who had completed a first-aid course in the last 5 years, 6 participants were excluded as they reported having followed their last BLS course more than 5 years before taking the questionnaire. Finally, the effect of the COVID-19 pandemic on the intention to perform resuscitation is not known as the survey was conducted prior to this crisis.
Control beliefs, one of the three dimensions of intention to perform resuscitation, decreased significantly within only 6 months after the last BLS course. Restoring this dimension to its immediate post-BLS course state should be the focus of future research to enhance CPR provision by lay rescuers in cases of OHCA. Far beyond technical issues, this can be achieved through short interventions aimed at building self-confidence and capacity to reinforce the need to act in the case of an emergency.
Original survey questions (in French) and English translation.
Univariate analysis of the three dimensions of the intention to perform resuscitation in first-aid course participants with a cutoff of 1 year since completion of the last course.
Univariate analysis of the three dimensions of the intention to perform resuscitation in first-aid course participants with the cutoff at 2 years since completion of the last course.
basic life support
cardiopulmonary resuscitation
out-of-hospital cardiac arrest
The authors would like to thank the Association Genevoise des Sections de Samaritains and Firstmed for having sent recruitment emails on their behalf.
None declared.