Preparedness regarding first response to emergencies in the community among graduate students: A cross-sectional study in India

Introduction

The care for the acutely ill has evolved over the last few decades.¹ Advances in emergency medicine, prehospital care systems and evidence-based medicine culminating into standard protocols for care has led to an improvement in outcomes.¹ Despite all advancements, the key step for optimal outcome of the patient in time-sensitive emergencies remains early identification of the illness, immediate activation of the emergency response system and often the initial care delivered by the bystander till further help arrives.² This is reflected in the American Heart Association's chain of survival for out of hospital cardiac arrest (OHCA), where the onus of the first three links in the chain are dependent on the community.² Hence, preparedness among the community is essential- more so in scenarios that require timely interventions by bystanders, such as OHCA, choking, stroke and myocardial infarction.

The global incidence of out of hospital cardiac arrest (OHCA) is estimated to be 55 per 100,000 person-years,³ making it an important public health challenge. The outcome of these patients depends on early recognition of cardiac arrest, immediate bystander cardiopulmonary resuscitation (CPR) and early defibrillation.^4,5 Bystander CPR initiated in witnessed ventricular fibrillation arrests has shown to improve survival from 42 to 65%.⁵ There is a wide global variation in the rate of bystander CPR. Bystander CPR rate in countries like the USA (45.7% in adults and 61.4% in children)⁶ and Sweden (68.2%)⁷ are much higher than in India (9.8%)⁸ The International Liaison Committee on Resuscitation Advisory has a hypothetical formula called the “Utstein formula for survival from cardiac arrest”, which suggests, survival = guideline quality × education efficiency × local implementation.⁹ The studies done in India are mainly focused on medical students, and they show inadequate knowledge regarding CPR.¹⁰ Studies regarding knowledge of automated external defibrillator (AED) in India are lacking as well.

Thus, this study aimed to assess the preparedness regarding the first response to emergencies among the graduate students at a university in India across various disciplines and explore their perspective on CPR and AED. This study will provide us with crucial information that will enable us to appeal for and plan nationwide programs for emergency first response training in India.

Methods

Results

Using cluster random sampling, classroom batches were randomly selected. A total of 1930 students were approached. Among them 1851 students agreed to participate in study. All students who agreed to participate, completed the questionnaire with no missing data. The total number of responses received were N = 1851. The Cronbach’s alpha of the knowledge assessment questionnaire was 0.880 suggesting good internal consistency. The median (interquartile range) age of the study participants was 20 (19-21) years. The study included both HCPT students and non-HCPT students. Non-HCPT students formed the vast majority (n = 1187/1851; 64.13%). The demographic characteristics of the study participants are tabulated in Table 1.

The proportion of participants who gave the right responses to various knowledge assessment questions and a comparison between non-HCPT and HCPT students are summarized in Table 2. Some of the significant observations we found were that only 61.48% (n = 1138) knew the emergency helpline number. Some themes were associated with poor knowledge, even among the HCPT students, including recognising cardiac arrest and correct initial response (33.98%), awareness about hands-only CPR (12.26%), rate of chest compressions in adults (25.01%) and infants (19.67%), steps while using an AED (17.45%), and resuscitation of an unresponsive choking infant (15.94%). Very few participants were aware that AEDs are available at airports (n = 750/1851; 40.52%) and railway stations (n = 377/1851; 20.37%).

In terms of CPR, 29.17% (n = 540/1851) had undergone previous training in CPR and 20.91% (n = 387/1851) had previously witnessed a cardiac arrest. When data from HCPT students was compared with non-HCPT students, the proportion of HCPT students who either underwent CPR training (63.82% versus 10.87% respectively; p < 0.001) or witnessed a cardiac arrest (25.78% versus 18.62% respectively; p = 0.001) was significantly higher. Among the students who had witnessed a cardiac arrest (n = 387) 28.68%, with a close to equal proportion in both non-HCPT (n = 62/221, 28.05%) and HCPT (n = 49/166; n = 29.52%) groups, felt that the situation could have been handled better. Also, 85.27% (n = 330/387) felt that they could have helped if they were previously trained.

Table 3 summarizes the participants’ responses on their perspective towards providing CPR and the use of AED. Only 57% (n = 1055) of participants were willing to initiate CPR in cardiac arrest victims. Some of the barriers identified included no prior training (62.4%), perceived harm to the victim (26.9%), belief that CPR may lead to contraction of disease (17.88%), harm to the provider due to AED use (17.94%), and religious and cultural barriers (12.91%). Further, non-HCPT students believed that they lack the ability to use an AED (OR = 11.803, p < 0.001) and were unwilling to use an AED even after training (OR = 2.466, p < 0.001). On average, non-HCPT students had increased odds (approximately two times) for unfavourable attitudes towards CPR when compared to HCPT students.

The mean knowledge score was 20.12 (11.26) out of 50 [15.66 (7.74) in non-HCPT students versus 28.10 (12.13) in HCPT students; p < 0.001]. The proportion of participants who scored less than 50% was 1278 (69.04%) of which n = 1026/1278 (80.28%) were non-HCPT students (OR = 10.419; p < 0.001). The details of the univariate and multivariate analysis evaluating predictors for the knowledge score are summarized in Table 4. The significant predictors (ß coefficient of multivariate analysis; 95% CI; p value) of knowledge score were lower age (0.374; 0.140, 0.608; 0.002), male gender (1.561; 0.699, 2.332; <0.001), non-HCPT students (6.159; 5.162, 7.155; <0.001), No previous training in CPR (10.594; 9.560, 11.628; <0.001) and not witnessed a cardiac arrest before (2.588; 1.619, 3.556; <0.001)

Discussion

Successful outcomes in time-sensitive emergencies involve a pivotal role played by people in the community in identifying and initiating emergency response.² Our study was done among students pursuing graduation in a university and had a pan-India representation of participants, this formed a window for us to understand the community awareness and perspective regarding first response.

Activation of the emergency response system is a crucial step in initiating emergency care. In our study, we noted that only 33.9% of participants knew how to recognise cardiac arrest and only 61.48% knew the helpline number for activation of the emergency response system. Aroor et al and Modi et al also found low awareness (56.3% and 76.2% respectively) of the emergency helpline number in India.^10,13 A study done by Schuffelen et al in the Netherlands, among the school students, found 81.3% were aware of the emergency helpline number.¹⁴ This forms the first link in the chain of survival and hence is essential. This dismal number of educated graduates who know this number in India, highlights the importance to scale up efforts towards creating awareness in the community.

In our study, we noted that only 29.1% of the students pursuing graduation had previous training in CPR, For those outside HCPT a mere 10.87% had previous training. Qara et al from Saudi Arabia had reported that only 28.7% of the 600 non-medical professionals interviewed had prior training in CPR.¹⁵ In contrast, the training rates are higher in countries such as the USA, Canada, and South Korea.^16–18

One of the potential solutions to improve community training rates is school CPR training programs. Unlike in some countries, India does not have a robust school CPR training program. The World Health Organisation recommends CPR training in secondary schools and to include it as part of national legislation.¹⁹ This will ensure a large population is trained and has been listed as a key component to raise bystander CPR rates.^20,21

The knowledge score was considered poor (<50%) in 69% of the participants. A study from Karnataka state, India conducted among school teachers revealed that 87% (n = 127/146) had moderate knowledge but none were in the good knowledge category.²² A similar study conducted among HCPT students in South India found that the mean score was approximately 42% (poor knowledge).¹⁰ However, all these studies have used different tools to assess knowledge so these numbers may not be directly comparable. The awareness and knowledge has been found to be low in other developing countries as well.^23–25

We noted that the participants in our study lacked knowledge regarding aspects of CPR such as hand placement during CPR (47.43%), rate and depth of compression (25.01% and 43.81% respectively) and hands-only CPR. In India, another study found that only 5.47% (n = 8/146) knew the correct procedure of CPR.²² Similarly, a study by Urban et al had found that only 23.3% had knowledge regarding hands-only CPR.²⁶ In contrast, a nationwide survey in Taiwan found that 57.5% of participants knew how to perform CPR.²⁷

We found 51% of our participants knew the function of an AED and 17.45% of respondents knew the steps of using an AED. However, participants had low awareness of the availability of AED at railway stations and airports. Another Indian study among HCPT students found that only 11.3% (n = 59/520) knew what an AED stands for¹⁰ Similarly, a study in Hong Kong also revealed that 77.6% did not know the location of AEDs in their vicinity/workplace.²⁸

In our study, although only 57% were willing to start CPR, 80.33% of respondents believed CPR could save lives and 83.3% were willing to undergo CPR training. The most common barrier for the willingness to performing CPR was the lack of prior training, followed by a belief that CPR may harm the victim. A Chinese study revealed 76.3% were willing to perform CPR on strangers and 53.2% were worried about legal issues.²⁹ A survey among adults in the UK reported that people who received prior CPR training were 3.4 times more likely to be willing to perform CPR compared to people with no training. Similarly, people trained in AED use were 2.62 times more likely to go, get or use an AED.³⁰ Hence, training the participants in CPR and dispelling the myths regarding CPR is essential to increase the bystander CPR rates in the community. The positive attitude of the students towards the usefulness of CPR and readiness to undergo training is encouraging and was the silver lining of our study.

Analysis for predictors of knowledge score revealed that with every year of increased age, the average score is likely to increase by 0.374 units. HCPT students are most likely to have their mean knowledge scores higher by 10% compared to their non-HCPT peers. On a similar note, those who underwent prior training or who have witnessed a cardiac arrest before are likely to score better by an average of 9.5 and 1.5 units respectively. These findings once again stress the importance of formal training and hands-on experience as the sole driver of better awareness and knowledge.

Conclusions

There is a lack of preparedness regarding the first response to emergencies. The knowledge regarding the first three links of the chain of survival- activation of emergency response, high quality CPR and defibrillation in cardiac arrest was lacking among our participants. Only 61.48% knew emergency response helpline number, 33.98% knew to recognise cardiac arrest and initiate response, 25.01% knew rate of compressions and 43.81% knew depth of compressions which form components of high quality CPR, 17.45% knew steps of using an automated external defibrillator. Each link is integral to improve the survival of patients with OHCA. These alarming statistics warrant immediate acceleration of CPR training programs among the community, as well as have training and refresher programs among the HCPT students and graduates. We recommend that methods such as inclusion of school CPR training programs in curriculum, use of social media to disseminate information, innovative contests to attract community participation,³¹ CPR training for receptive population such as new parents and relatives of cardiac patients prior to discharge,³² in addition to the existing community CPR training programs could be used to increase the awareness about CPR and AED.

Willingness to learn CPR among the participants was the silver lining in the study.

Data availability