Survival from out-of-hospital cardiac arrest (OHCA) varies across the developed world. In 2013 Seattle, USA, had one of the best OHCA survival to discharge from hospital rates at 22% [1]. In contrast resuscitation is attempted for approximately 3,000 adults who experience out-of-hospital cardiac arrest (OHCA) each year in Scotland with only 6% surviving to hospital discharge [1]. Although not all OHCA are recoverable, the survival rate in Scotland is lower than in comparable countries, with higher average survival rates of 7.9% in England [2] and 9% across Europe [3]. There is also considerable regional variability in survival outcomes with cities like Stavanger in Norway reporting survival rates as high as 25% [3,4]. While these figures should be interpreted with caution (due to variation in the way data is presented) there is a clear public health policy agenda to improve survival after OHCA in Scotland.

The experience of other national OHCA survival programmes has shown that increasing bystander CPR improves overall survival [5]. In Sweden a CPR training strategy resulted in three million people being trained in CPR (population 9.5 million) during the last three decades [6]. By 2011 the CPR rate had risen from 31% to over 70%—amongst the highest in the world—with a parallel increase in OHCA survival to one month from 5% in 1992 to 11% in 2011 [7].

In 2015 Scotland launched a national strategy for out-of-hospital cardiac arrest with the ambition that by 2020 Scotland becomes an international leader in OHCA outcomes [1]. The overall aim is to save an additional 1,000 lives by 2020. Crucial to achieving this is to increase rates of bystander CPR—currently estimated to be around 50% [8].

To help meet this aim a cross-sectional survey of the Scottish population was conducted in 2015 to explore public attitudes, awareness and perception of bystander CPR. This paper presents survey findings focusing on the current prevalence of CPR training and modifiable factors (such as barriers to administering bystander CPR) which could inform future policy and initiatives to improve the rate of bystander CPR.

Data collection took place between 5^th-18^th August 2015 via the Scottish Opinion Survey (SOS). The SOS is an omnibus survey administered by social research agency, KANTAR Public UK (formerly TNS-BMRB). Survey questions and pre-coded answer options were developed by the research team after reviewing the literature. These were then reviewed and discussed with the project steering group and further refinements were made to reach the final set of questions.

Random household location quota sampling was used to generate a sample of 1027 adults aged 16 and over across Scotland, selected by age, gender, working status and number of children in the household. Weights were applied to the sample to be representative of the adult population. Interviews were conducted face-to-face, in the home (one interview per household), by trained market research interviewers via a computer programme called CAPI (Computer Assisted Personal Interviewing). Verbal consent was obtained before data collection took place. Ethical approval was obtained from the University of Stirling’s School of Health Sciences committee prior to data collection.

Demographic information included age, gender, working status and social grade. Social grade was determined using the National Readership Survey (NRS) based on the occupation of the chief income earner in the household. Social grade ‘ABC1’ includes professional, managerial and non-manual occupations, while ‘C2DE’ includes manual and unskilled occupations and the long-term unemployed.

The purpose of this cross-sectional survey was twofold. First, baseline data on the number of people trained in CPR has been collected to help monitor progress of the OHCA strategy in Scotland. Second, in order to inform future policy and initiatives to improve the rate of bystander CPR, the barriers and facilitators to administering bystander CPR were explored.

Despite over half (52%) of respondents being trained in CPR, two fifths (44%) had received this training over five years ago. Among those who were not trained, 42% expressed a willingness to be trained in CPR. One fifth of the whole sample (21%) would not know if CPR was required and a further 50% would not feel confident administering CPR. These findings suggest that if Scotland is to become an international leader in OHCA outcomes more needs to be done to improve levels of confidence to administer bystander CPR if required, especially among older age groups and people with lower social grade.

However, respondents did show a willingness to administer bystander CPR if they were the only person present (72% of respondents said they would be extremely or somewhat likely to do so). This is surprising given the low level of confidence, but may be explained by results from other research. Johnston et al (2003) found that CPR by an individual was more likely where they thought no one else was present and less likely where they were not alone. This could be due to the Bystander Effect: the diffusion of responsibility when there are many people present in an emergency situation [9].

Reasons for the lack of confidence to administer bystander CPR identified in our sample were congruent with existing evidence from a number of countries, which points to a range of individual and environmental factors [10–14]. Individual factors focus on the perceptions, knowledge and CPR experience of the person witnessing a cardiac arrest. One of the most common reasons for unwillingness to intervene in OHCA is fear of causing more harm [12,13]. This was the main barrier from our survey cited by 22% of respondents. Moreover, there is a perception that this fear will be exacerbated in an emergency situation through panic [10–14]. Several studies note that bystanders are more willing to perform CPR on children and young adults than on older people or socially excluded groups (i.e. intravenous drug users or homeless people) and can be put off by physical presentation; e.g. presence of vomit or dentures, for example [11, 15–17]. Our results are consistent with this literature with visible signs of vomit/blood, or a concern that the victim may be a drug user being some of the most common barriers. It is notable that when respondents were asked to identify reasons why they may not administer bystander CPR, 33% said that none of the pre specified reasons were relevant to them. This suggests that further qualitative research is required to enhance understanding of the potential barriers to administering bystander CPR.

Concerns about legal action (such as being sued) for attempting CPR did not feature strongly in our sample, with just 8% citing this as a barrier. This is consistent for countries without a strong personal litigation culture such as Scotland, but has been identified as a barrier in countries that do, such as the USA [14,18].

The more economically deprived an area is, the higher the rate of cardiac arrest—but survival rates are lower [19]. However studies have shown that, currently, bystander CPR intervention is higher in wealthier than deprived areas [19,20]. This suggests the need for optimal bystander CPR intervention in more deprived areas. In Scotland, a similar social gradient in OHCA and CPR response has been found. As levels of deprivation rise so do rates in OHCA, but bystander CPR interventions fall [1]. Our multivariate analyses identified that employment status and social grade (which influence levels of deprivation), along with age, were significant factors affecting bystander CPR. People in social grade C2DE were less likely than those in social grade ABC1 to be CPR trained and less confident to administer CPR if talked through by a call handler. Finally, the older a person was, the less likely they were to be CPR trained, show willingness to be CPR trained or be confident to administer bystander CPR. These findings are particularly relevant considering that most OHCA happen in the homes of older people [21], and they provide a clear indication of where future efforts need to be targeted if rates of bystander CPR are to be improved.

From a policy perspective there is a need for more tailored and targeted interventions to encourage CPR training which has been linked with improving confidence in CPR. As this increases, so does the likelihood of providing emergency aid in an OHCA [17,22]. Our findings suggest that priority groups are people who are not working, in a lower social grade and the elderly.

Our study has limitations. First, the pre-coded answer options for the survey may have influenced responses and there may have been factors influencing responses which we did not capture in our questions. Second, our results were limited to a cross-sectional survey from a random location quota sample which is a non-probability sampling approach. As a result, no detail is available on response rate and the results are not necessarily generalisable to the wider population. Finally, we were not able to add to the literature around optimal approaches to engage local communities to take part in CPR training and build confidence. Instead, this is a current focus for future work in a new study funded by the Chief Scientist’s Office of the Scottish Government.

In a developed country such as Scotland with widely available CPR training, only half of the adult population reported feeling confident about administering bystander CPR. Further efforts tailored specifically for people who are older, unemployed and have a lower social grade are required to increase knowledge, confidence and uptake of training in bystander CPR in order to improve cardiac arrest survival.