Abstract
Background
Out-of-Hospital Cardiac Arrest (OHCA) is a significant global public health concern, with survival rates ranging from 2% to 11%. Bystander Cardiopulmonary Resuscitation (CPR) is crucial for improving survival rates. However, public willingness to perform CPR varies widely because of many determinants. This study aims to systematically synthesize qualitative evidence on the determinants of public participation in Out-of-Hospital Cardiopulmonary Resuscitation (OHCPR). It provides insights for enhancing public engagement in emergency response.
Methods
Following the Joanna Briggs Institute (JBI) methodology for qualitative systematic reviews, a comprehensive search was conducted across six electronic databases (PubMed, Web of Science, Embase, CINAHL, ProQuest, and The Cochrane Library) for studies published up to February 2025. Data extraction and thematic analysis were conducted to identify themes and sub-themes. This study is registered with PROSPERO (CRD42024593820).
Results
The analysis identified 10 categories and synthesized into 3 themes: (1) The Situational Web, which includes patient characteristics and need for assistance; (2) Knowledge, skills and training, highlighting the impact of first aid knowledge and training on willingness to act; and (3) Inner Self, focusing on intrinsic drive and·psychological distress. These themes collectively shape public decision-making in emergency situations.
Conclusions
Public participation in OHCPR is determined by a complex interplay of the situational web, knowledge, skills and training, and inner self. Enhancing public training programs, providing clear guidance, and addressing psychological barriers are crucial for improving the willingness of bystander intervention. Future research should focus on optimizing training effectiveness and addressing cultural and regional differences to further enhance public participation in CPR.
Keywords
Introduction
Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency in which the heart stops beating outside of a hospital setting, which disrupts blood circulation and oxygen delivery. OHCA is a significant global public health concern (Cummins et al., 1991; Myat et al., 2018), with an annual incidence of 95.9 cases per 100,000 adults worldwide (Porzer et al., 2017) and survival rate range from 2% to 11% (Fan et al., 2017). Without immediate intervention, survival rates decrease by 7-10% per minute (Larsen et al., 1993), whereas the median emergency medical service (EMS) response time is 5-8 minutes (Perkins et al., 2015). During these critical ‘golden minutes’, prompt Cardiopulmonary Resuscitation (CPR) by first responders can significantly improve outcomes (Sun, 2023). Since accidents and injuries in the community are generally more common than in hospitals (Al-Khatib et al., 2018), and OHCA often occurs in the community, ordinary members of the public in the community are often the first to encounter and potentially provide assistance for OHCA cases. Therefore, analyzing the factors that influence public decision - making in OHCA emergency scenarios is crucial for enhancing social and economic benefits through increased public involvement in OHCA emergency response.
Recently, there has been a surge in qualitative studies on public participation in Out-of-Hospital Cardiopulmonary Resuscitation (OHCPR). However, the existing findings are inconsistent, and a comprehensive and systematic review is absent. For instance, investigations highlight that individuals in impoverished communities are less likely to offer assistance due to safety concerns and fear of retaliation (Dobbie et al., 2020; Sasson et al., 2013). Religious and philosophical beliefs also influence the public’s willingness to provide aid (Skora & Riegel, 2001). These disparities underscore the impact of regional culture, economic circumstances, and social structures on public emergency response behavior, thereby limiting the generalizability of conclusions drawn from individual qualitative studies. A meta-analysis of OHCPR willingness revealed that public knowledge, beliefs and behaviors influence the likelihood of providing first aid (Cheng et al., 2025). However, this analysis relied mostly on cross - sectional and unifactorial analyses, which fail to capture complex interactions between factors. Qualitative studies, however, can provide rich insights into these multifaceted determinants, including psychological and social dimensions. Therefore, integrating existing qualitative studies through a systematic review could provide a more comprehensive understanding of the determinants of public participation in OHCPR and inform the development of more effective intervention strategies. To the best of our knowledge, no systematic review of qualitative studies on the determinants of public participation in OHCPR has been published. This study intends to use the Joanna Briggs Institute (JBI) qualitative research systematic evaluation method to integrate and analyse the relevant qualitative research.
Methods
Aims and Design
This study aimed to systematically synthesize qualitative evidence on the public’s willingness to participate in OHCPR. The protocol has been registered with PROSPERO (CRD42024593820) and follows the JBI Methodology Manual guidelines (Lockwood et al., 2020). Our research report follows the ENTREQ Statement on improving transparency and quality in reporting Qualitative Research (Tong et al., 2012).
Search Strategy
This study strictly followed the standardized procedures outlined in the “JBI Methodology Guidelines” (Lockwood et al., 2020) for the search process, which consisted of three core steps. First, a preliminary search was conducted using the PubMed database to analyse the professional terms in the titles and abstracts of the literature, as well as the article keywords. Second, a multi-database combined search strategy was employed, including PubMed, Web of Science (Core Collection), Embase, CINAHL, ProQuest, and The Cochrane Library. This strategy integrated subject terms and free words for a systematic search, primarily covering three categories of keywords: Cardiopulmonary Resuscitation, willingness, and qualitative research. Third, further screening of relevant studies was performed by reviewing the references of the included literature. During the literature screening process, necessary snowballing-style searches were implemented. In addition, manual searches were conducted on some well-known journals that published high-quality research results in our field of interest. The search scope was limited to papers published between the establishment of the database and February 6, 2025. The complete search strategy is presented in Supplemental 1.
Inclusion and Exclusion Criteria
The inclusion criteria included: (1) The study participants must be members of the public, including both medical professionals and non-medical individuals; (2) The phenomenon of interest includes barriers and facilitators influencing the public’s willingness to provide CPR; (3) The context involves situations where the public encounters OHCA; (4) The study must be in qualitative approach including descriptive qualitative studies, those applying phenomenology, grounded theory, and other qualitative research methodologies. Exclusion criteria: (1) the full text or insufficient data of the literature cannot be obtained; (2) Non-English literature; (3) Conference, abstract or literature review.
Study Screening and Selection
The literature was imported to EndNote, and duplicate entries were removed. Subsequently, by reviewing the titles and abstracts, studies unrelated to the topic and satisfied exclusive criteria were excluded. Finally, a full-text review was conducted for further screening. Two researchers (YC and CZ), trained in qualitative research and evidence-based nursing, independently screened the literature, extracted data, and cross-checked their findings. In case of disagreements, the third researcher (WN) was consulted to assist in making the final decision. Finally, data extraction was performed on the included studies, covering details such as authors, year of publication, country, research methodology, participants, phenomenon of interest, and main findings.
Methodological Quality
The methodological quality of the study was assessed using the Joanna Briggs Institute Qualitative Assessment Review Instrument (JBI-QARI). The tool consists of 10 items, each of which is rated as “Yes,” “No,” “Unclear,” or “Not Applicable”. A “yes” was scored as 1, and other ratings were scored as 0, the maximum score was 10. Initially, two researchers conducted independent evaluations. If the two researchers did not agree on their assessments, the discrepancies were resolved through discussion. In cases where the two could not agree, a third researcher was invited to participate in the discussion.
Confidence Analysis
The Credibility of Evidence for Qualitative Research Synthesis (CERQual) method (Lewin et al., 2015) was used to assess the credibility of the evidence. The method assesses the credibility of qualitative evidence through four components: methodological limitations, relevance, consistency, and adequacy of data, with the main objective of determining the extent to which the review results accurately reflect the phenomenon under investigation.
Data Extraction and Analysis
The authors performed a data extraction of the articles and collected information such as the author’s name, year of publication, country, purpose of the study, number of participants, and main findings for each included study. This information was then recorded on a data extraction form. This review used inductive analysis to organize and synthesize the qualitative data through three stages. In the first stage, the data were coded line by line. In the second stage, similarities and differences between the codes were analysed and the codes were grouped to form descriptive themes. In the third stage, the researcher described or interpreted the descriptive themes through continuous review and synthesis. During this process, any disagreements between the two authors were resolved through discussion with the third researcher.
Findings
Study Selection
A total of 15,044 studies were searched through databases, and 189 studies were browsed in full text after removal of duplicate entries and screening of titles and abstracts using EndNote software. Ultimately, 17 studies met all inclusion criteria for this review (Figure 1). Literature retrieval and screening process
Quality Appraisal
Results of the Critical Appraisal of the Studies Included
Y, yes; No, no; U, unclear.
Q1, congruity between the stated philosophical perspective and the research methodology; Q2, congruity between the research methodology and the research question or objectives; Q3, congruity between the research methodology and the methods used to collect data; Q4, congruity between the research methodology and the representation and analysis of data; Q5, congruity between the research methodology and the interpretation of results; Q6, statement locating the researcher culturally or theoretically; Q7, statement of the influence of the researcher on the research; Q8, represent of the participants and their voices; Q9, ethical approval by an appropriate body; Q10, Relationship between the conclusions and analysis or interpretation of the data.
Study Characteristics
Basic Characteristics of Included Studies (n = 17)
aAED: Automated External Defibrillator.
Main Findings
In thirteen articles, we identified nine categories and three main themes. The first theme highlights external contextual factors that collectively form the situational web influencing public decision-making. The second theme emphasizes how the public’s knowledge, skills, and CPR training experiences affect their willingness to participate in CPR. The third theme describes intrinsic motivations and emotional and psychological barriers. These factors determine the public’s willingness to engage in OHCPR. Notably, training experience enhances public knowledge and skills and is also associated with their intrinsic motivations to participate in first aid. An overview of these themes is illustrated in Figure 2. Overview of the themes
The Situational Web
The theme “The Situational Web” reveals external situational factors influencing public willingness and ability to respond to OHCA. It includes two sub-themes: “patient characteristics” and “need for assistance”, which highlight the external challenges faced by the public in emergencies.
Patient Characteristics
Patient characteristics are key factors influencing public willingness to perform CPR. Bystanders often withhold mouth-to-mouth ventilation when the victim presents undesirable features such as cyanosis or obvious signs of death, fearing futility as well as oral fluid exposure (Axelsson et al., 2000; Cheskes, 2014; Hansen et al., 2017; Sun et al., 2024). Gender differences play a role, as some male bystanders discomfort with exposing and touching a female victim’s chest, especially in public space (Charlton et al., 2023; Sasson et al., 2015; Sun et al., 2024). Age further shapes the decision. Rescuers worry that performing chest compressions on a child may cause physical harm because the body is immature (Sasson et al., 2015), whereas elderly victims are sometimes perceived as having lower life potential, reducing the perceived value of intervention (Cheskes, 2014; Yang et al., 2024). The relationship between rescuer and victim further impinges on the decision. Some prefer to help relatives because it feels natural (Cheskes, 2014; Sasson et al., 2015; Sun et al., 2024; Yang et al., 2024), whereas others favor strangers to reduce emotional load and stay calm (Charlton et al., 2023; Cheskes, 2014; Dobbie et al., 2020). Individuals who have previously lost a loved one are more inclined to act, possibly as a way of post traumatic mastery (Charlton et al., 2023). “I think its people’s parental instinct. I think most people, not all people, but I think most people kind of feel that you know it’s worse if a younger person dies than an older person and because they have their whole lives ahead of them. You know it’s a maternal or paternal instinct that I think a lot of humans have.” (Cheskes, 2014)
Need for Assistance
The absence of support and assistance from others can lead bystanders to feel abandoned, diminishing their willingness to intervene (Axelsson et al., 2000; Chen et al., 2020). Although team presence generally increases intervention rates (Hansen et al., 2017), multiple on scene voices shouting different directions often overload the rescuer, who may stop compressions while trying to regain confidence and thus create critical CPR pauses (Shimamoto et al., 2020). Bidirectional dispatcher contact allows the caller to report complications and receive adjusted instructions in real time, thereby improving CPR quality (Mathiesen et al., 2017; Sasson et al., 2015). The voice prompts of automated external defibrillators (AEDs) offer a single consistent command source that prevents multi voice chaos and reassures the user (Hansen et al., 2017; Shimamoto et al., 2020). Therefore, effective assistance requires a clear channel and the elimination of competing advice, otherwise the presence of helpers can rather inhibit action. “I just cried out, ‘is there anybody who can help me!’ but no, they just passed by.” (Axelsson et al., 2000)
Knowledge, Skills and Training
The theme “Knowledge, Skills and Training” highlights how the public’s current knowledge and skills and their past training experiences shape their willingness to respond to OHCA. It includes two distinct but interrelated sub-themes: “Knowledge and Skill Level”, which describes what people know and can do, and “Training Experience” which refers to whether, when and how they received first aid education and how this influences them to take action in emergencies.
First Aid Knowledge and Skill Level
Many bystanders lack sufficient first aid knowledge, which directly limits their ability to recognize cardiac arrest and perform CPR effectively (Shimamoto et al., 2020; Sun et al., 2024; Yang et al., 2024). People often failing to recognize cardiac arrest symptoms and confusing “cardiac arrest” with “heart attack” (Case et al., 2018; Chen et al., 2020; Dobbie et al., 2020; Mathiesen et al., 2017; Mausz et al., 2018). AED use was commonly perceived as technically difficult, even when the device was available (Mausz et al., 2018; Shimamoto et al., 2020). “When I saw him on the floor, he’s not moving, he’s turning blue, something is clogging something, right?” (Mausz et al., 2018)
Training Experience
Training experience plays a critical role in the public’s willingness to provide first aid. Individuals who had never received training routinely attributed their inaction to “not knowing what to do” and “being afraid of making things worse” (Cheskes, 2014; Dobbie et al., 2020; Hansen et al., 2017; Munot et al., 2023; Sun et al., 2024), whereas trained individuals report greater knowledge and a stronger intention to intervene (Charlton et al., 2023; Hansen et al., 2017; Mathiesen et al., 2017; Shimamoto et al., 2020). However, the benefit of training erodes over time. Skills proficiency could decline within months (Axelsson et al., 2000; Yang et al., 2024) and ever-changing resuscitation guidelines leave past trainees unsure of the current protocol (Sasson et al., 2013). Consequently, some trained bystanders still panicked and worried about delivering substandard chest compressions, thereby incurring the hesitation they had originally sought to overcome (Sasson et al., 2013). “We only received training when obtaining the security certificate over ten years ago. They discussed CPR during the training, but there hasn’t been any further training since then. Additionally, it’s been a long time since the training, and I’ve forgotten much of the content. There have been no updates.” (Yang et al., 2024)
Inner Self
The theme “Inner Self” describes the public’s internal psychological state and motivations when confronted with OHCA. These intrinsic factors significantly influence their willingness to respond. This theme includes two sub-themes: “Intrinsic drive” and “Emotional and psychological impairments”.
Intrinsic Drive
Intrinsic drive is a key factor influencing the public’s willingness to perform CPR. It arises from respect for human life, altruistic desires to help others, and awareness of their responsibility in emergencies. Among these, altruism is a core motivation (Axelsson et al., 2000).
Altruism
Altruism serves as a significant intrinsic motivation for the public to engage in CPR, manifesting in bystanders respect for human life and their inherent willingness to assist others. This motivation is rooted not only in a reverence for life but is also profoundly shaped by the Golden Rule, which emphasizes that everyone deserves assistance, irrespective of their status or circumstances (Mathiesen et al., 2017; Shimamoto et al., 2020; Skora & Riegel, 2001). For instance, many participants reported that they acted without hesitation despite discomfort or potential risks, driven by the belief that “if I can help, I will” (Axelsson et al., 2000; Shimamoto et al., 2020). This profound respect for life and the conviction to save inspire the public to act decisively in emergency situations. “It was a bit unpleasant when I felt that phlegm coming up, which I had to deal with, of course it does, but the other thing takes over…the wish to help.” “…it was only natural, if I can help I’ll do it.” (Axelsson et al., 2000)
Furthermore, bystanders frequently hold the belief that life is invaluable. Even when faced with an individual who may appear deceased, they feel compelled to do their utmost to help, as “this is still a living being deserving of our best efforts” (Axelsson et al., 2000; Skora & Riegel, 2001; Sun et al., 2024). This profound respect for life and the conviction to preserve it further reinforce the altruistic behavior exhibited by the public.
Instinct and responsibility
The public’s willingness to respond to OHCA cases is further influenced by instinct and a sense of responsibility. Instinctive reactions compel bystanders to act swiftly in emergencies, while a sense of responsibility further strengthens their willingness to intervene. Many bystanders reported feeling a compelling internal urge to “do something” when faced with a cardiac arrest patient (Axelsson et al., 2000; Chen et al., 2020; Shimamoto et al., 2020; Sun et al., 2024). Others viewed assisting others as a fundamental responsibility of being a community member, increasing their likelihood of taking proactive rescue measures during OHCA incidents (Axelsson et al., 2000; Hansen et al., 2017; Mathiesen et al., 2017). Individuals who have undergone first aid training often develop a strong sense of rescue responsibility, rooted in the knowledge and skills they have acquired (Axelsson et al., 2000; Skora & Riegel, 2001). Additionally, social pressure has also pushed the public’s sense of responsibility to some extent. Many bystanders expressed their fear that they might be blamed by social opinion or self-moralized if they did not take action at the scene of an OHCA (Skora & Riegel, 2001). “Conscience, or one’s own social morality. I think this is the basic instinctive behavior of ordinary people who accumulate virtue and do good deeds. It can also be said that this is a very natural performance.” (Sun et al., 2024)
However, the perception among some individuals that first aid is the duty of professionals rather than their own responsibility diminishes their willingness to intervene (Charlton et al., 2023; Dobbie et al., 2020; Munot et al., 2023; Yang et al., 2024). “If my car breaks down, they send a mechanic. If someone breaks down, we send an ambulance and they’ll deal with it.” (Charlton et al., 2023)
Emotional and Psychological Distress
Emotions and psychological distress are the core obstacles that restrict public participation in OHCPR. Their formation is perhaps not the result of a single factor, rather a complex product of the interaction between immediate situational stimuli and negative perception and feelings of oneself towards OHCPR. These may stem from the psychological defense responses of humans in the face of sudden crises as well as individuals past life experiences and perception of risks in the social environment. Ultimately, these factors jointly weaken the public’s willingness to provide rescue. Based on the comprehensive results of the included studies, emotions and psychological distress can be further decomposed into four specific categories. These categories respectively correspond to various types of psychological obstacles for the public in responding to OHCA scenario and together form a resisting force in one’s inner self to participation in OHCPR.
Psychological Shock
The sudden and unpredictable nature of OHCA events is a key factor contributing to psychological shock. This shock can easily cause the public to experience cognitive confusion and emotional instability, thereby inhibiting the effective initiation of rescue actions. At the cognitive level, most bystanders report that the incident was beyond their imaginable script (Mathiesen et al., 2017), producing decisional paralysis that can persist even during dispatcher-assisted calls (Charlton et al., 2023). Affectively, the life-threatening context evokes intense fear and anxiety; witnessing the patient’s rapid physiological decline precipitates acute emotional distress that lowers the propensity to act (Case et al., 2018; Charlton et al., 2023). Additionally, the abrupt imposition of a “life-guardian” role binds the bystander to the victim’s survival outcome (Shimamoto et al., 2020), transforming responsibility pressure into a sustained secondary shock that prolongs hesitation even among the CPR trained individuals (Donohoe et al., 2006).
Capability-Schedule Doubt
Capability-schedule doubt in the OHCA context is multifaceted and it encompasses both the self-doubt and schedule doubt. Self doubt arises from negative criticism of the accuracy of first aid made by the witnesses of the rescue incident while schedule doubt refers to the anxiety that intervening will disrupt personal commitments. Regarding self doubt, bystanders question the correctness of their actions when expected signs of life do not appear (Axelsson et al., 2000), and this uncertainty erodes confidence, leading to hesitation or even abandonment of resuscitation (Cheskes, 2014; Skora & Riegel, 2001; Sun et al., 2024). Untrained individuals worry that chest compression may break ribs or puncture organs (Case et al., 2018; Chen et al., 2020; Cheskes, 2014), whereas trained individuals may rescuers fear foe “skill forgetting” (Yang et al., 2024). Previous failed resuscitation experiences further intensify self-doubt and reduce future willingness to act (Dobbie et al., 2020; Yang et al., 2024). Regarding schedule doubt, the anticipation of missing appointments or being late for work could possibly show hesitation to step into the rescue scenario (Sasson et al., 2013). Both doubts may develop into a dual hesitation mechanism that significantly delays or hinders the initiation of OHCPR.
Risk of Potential Litigation
Although many individuals are willing to assist, the potential legal risks perceived often make them hesitated (Charlton et al., 2023; Cheskes, 2014; Yang et al., 2024). Despite protections offered by the Good Samaritan Law in certain regions, some individuals still fear that they may be accused by those who lack knowledge of the law (Chen et al., 2020; Cheskes, 2014; Sun et al., 2024). Untrained individuals, in particular, are more likely to be fear of being sued for improper handling of the situation (Donohoe et al., 2006; Shimamoto et al., 2020; Yang et al., 2024). A lack of knowledge about Good Samaritan laws, combined with the misinterpretation that “making a mistake equals jail time,” creates a reverse responsibility fear that directly discourages residents in low-income communities from learning and performing CPR (Shimamoto et al., 2020). “If you do that to a person over here in this country and you break his sternum while you are doing it they are going to sue you … you are more liable in this country so you have to be very careful and if you are not trained then you shouldn’t.” (Donohoe et al., 2006)
Fear for Own Safety
Many people are worried about the risk of disease transmission during mouth-to-mouth resuscitation, especially during the COVID-19 pandemic (Charlton et al., 2023; Chen et al., 2020; Cheskes, 2014; Sasson et al., 2013). In addition, bystanders in economically disadvantaged areas may fear violence or retaliation after performing CPR, particularly if the victim is associated with gangs or criminal activity (Dobbie et al., 2020). These concerns for personal safety can make the public less willing to help in OHCA incidents (Cheskes, 2014; Mathiesen et al., 2017; Sasson et al., 2015). For example, a trained individual reported prioritizing her personal safety over administering CPR when encountering a cardiac arrest victim on the street (Cheskes, 2014; Sasson et al., 2013). This shows that even though people may want to help, environmental risks can prevent them from doing so. Thus, environmental risks may be a more significant factor than others in determining whether to intervene.
CERQual Summary of the Synthesized Findings
Summary of Findings and CERQual Assessments
Discussion
This meta-synthesis provides a comprehensive analysis of the factors influencing public willingness to perform OHCPR. The findings indicate that public decision-making during emergencies is shaped by a combination of external situational factors and internal psychological factors. Understanding these determinants is critical for increasing public willingness to administer CPR.
The theme of “the situational web” highlights the strong influence of external factors on public willingness to assist during OHCA. Patient characteristics, such as appearance and unpleasant conditions, may deter bystanders from performing CPR. Kanstad et al. (2011) found that unpleasant physical characteristics of cardiac arrest patients can cause hesitation among bystanders. Similarly, Axelsson’s (1999) study noted that bystanders who had previously performed mouth-to-mouth ventilation often preferred chest compressions alone in subsequent resuscitations, indicating that mouth-to-mouth ventilation is a significant barrier to CPR. Emotional factors also play a pivotal role in shaping bystanders’ actions during emergencies. Previous studies have shown that emotional closeness and a sense of responsibility are key motivators for bystanders to act (Hasegawa & Hanaki, 2023) Consistent with this, the current review found that bystanders are more likely to assist family members or children, reflecting an instinct to protect those perceived as vulnerable or close. However, some bystanders reported that rescuing a family member can trigger greater anxiety than rescuing a stranger (Cheskes, 2014), suggesting that emotional and psychological barriers are significant determinants to public OHCPR participation.
Bystanders may also feel isolated or unsupported during OHCA events, leading them to believe external assistance is necessary. Studies have shown that receiving support from other bystanders, guidance from dispatchers, or instructions from an AED can significantly boost bystanders’ confidence and willingness to act (Rasmussen et al., 2014). For instance, an analysis of OHCA event footage revealed that teamwork was frequently lacking, even when multiple bystanders were present (Linderoth et al., 2015). This underscores the importance of fostering a supportive environment that encourages cooperation among bystanders and provides clear guidance from dispatchers to enhance the likelihood of effective intervention. Future research and practice should prioritize optimizing external support systems to improve public emergency response. Specifically, increasing the availability of AEDs in public spaces and enhancing public training on their use can boost confidence in first aid. Additionally, the emergency medical service (EMS) system should strengthen dispatchers’ guidance capabilities to deliver timely, clear first-aid instructions to bystanders.
The meta-aggregation results indicate that the public’s lack of knowledge and skills is a significant barrier to the implementation of OHCPR, while prior first aid training experience significantly mitigates this barrier. Bystanders with limited knowledge and skills often hesitate due to a lack of confidence, which aligns with previous research findings (Chen et al., 2024; Cheng et al., 2025; Li et al., 2023). Previous study has demonstrated that over 80% of bystanders are uncertain how to respond in emergencies due to insufficient basic life support (BLS) knowledge and skills (Kanstad et al., 2011), and 67-80% of respondents view a lack of BLS knowledge and confidence as a major barrier to providing assistance (Kanstad et al., 2011; Shibata et al., 2000; Taniguchi et al., 2007). In contrast, those who underwent BLS training exhibited greater willingness to act and increased confidence. BLS training not only enhances the public’s knowledge and skills but also empowers them to take action, increasing the likelihood of intervention (Olasveengen et al., 2009; Swor et al., 2006; Taniguchi et al., 2007). Furthermore, additional studies have indicated that the frequency of CPR training correlates with higher willingness to perform CPR among trained individuals (Coons & Guy, 2009; Kuramoto et al., 2008; Lee et al., 2013; Urban et al., 2013). However, trained individuals’ CPR skills may deteriorate over time, leading to hesitation in emergencies. Therefore, it is important to provide regular training and continuous education to sustain the public’s CPR capacity. The American Heart Association (AHA) recommends standard CPR retraining every two years to reinforce public confidence in first aid and enhance rescue capabilities (Neumar et al., 2015).
Within the theme of “Inner Self,” this study explores the psychological and emotional factors influencing bystander first aid behaviors. Intrinsic drive emerged as a significant facilitator of public willingness to perform OHCPR. Bystanders are motivated to save lives or assist others, regardless of their familiarity with the victim. This motivation stems from altruism and a sense of moral obligation (Hall, 2016). However, some bystanders expressed a lack of responsibility toward others, believing that resuscitation should be left to professionals (Dobbie et al., 2018). Altruism and sense of responsibility may be shaped by social cultural background and personal values. In societies that prioritize collectivism and humanitarianism, the public may be more inclined to take action to save lives (Axelsson et al., 2000). However, it was also reported that some bystanders may also have a “fluke mind” towards emergencies or believe in karma, which has become a significant obstacle for the public to participate in emergency rescue operations (Munot et al., 2023), and this mindset may regard the victim’s fate as predetermined, so bystanders fear that first aid would “interfere” and thus hesitate to act.
Emotional and psychological distress are significant obstacles to the public’s performance of OHCPR. This study revealed that few bystanders have ever imagined encountering OHCA in real life, leading to panic in such situations. Panic was reported as the most common reason for trained bystanders not performing CPR (Swor et al., 2006). Individuals lacking confidence often fear that they may harm rather than help others, and this self-doubt may arise from a lack of CPR training (Rajapakse et al., 2010) or prior unsuccessful first aid experiences (Hasegawa & Hanaki, 2023). In this study, capability-schedule doubt is suggested to have constituted a dual hesitation mechanism. Uncertainty about correct chest-compression and fear of rib fractures or organ injury cause self-doubt (Taniguchi et al., 2012), and the anticipation of missing personal appointments adds a distinct, pragmatic layer of anxiety that can independently delay or prevent OHCPR initiation (Gu et al., 2022). Additionally, the risk of unintentionally harming others or facing legal consequences are critical deterrents (Huang et al., 2021).
Studies have shown that the public’s fear of disease transmission and pessimistic expectations about the patient’s condition are important factors that prevent them from performing CPR (Hauff et al., 2003). Such concerns are prevalent across populations, and even those with higher levels of knowledge may be deterred from administering CPR for fear of being infected with a disease (Kanstad et al., 2011; Ong et al., 2013). The results of this synthesis indicate that even trained individuals may experience reduced willingness to act due to emotional and psychological distress. Therefore, the inner self may determine an individual’s willingness to perform first aid, potentially outweighing other factors when deciding whether to intervene. Future research and practice should prioritize enhancing public intrinsic motivation while addressing psychological and emotional barriers. For instance, psychological education and simulation training can help the public overcome panic and self-doubt, boosting their confidence during emergencies. Additionally, public awareness campaigns should emphasize the public’s roles and responsibilities in emergencies to foster altruistic values. Simultaneously, strengthening legal protection mechanisms and clarifying exemption clauses for public first aid responders can mitigate the impact of legal risks.
This synthesis has several limitations. First, the literature search was restricted to English-language studies, potentially excluding relevant research in other languages and introducing linguistic bias. Future studies should incorporate multi-language literature. Second, the included studies exhibited significant heterogeneity in cultural and regional contexts, limiting the generalizability of the findings. Future research should focus on identifying context-specific factors across different cultures and regions. Finally, most current research focuses on developed countries; future studies should prioritize these understudied regions.
Practical Implications
This study provides valuable insights for policymakers, trainers, and the healthcare system to guide the formulation of strategies to enhance the public’s willingness to participate in OHCPR. The research results indicate that providing clearer legal protection for bystanders involved in OHCPR can effectively alleviate the fear of potential lawsuits, which is a significant obstacle identified in this study. Concurrently, conducting extensive public education campaigns that emphasize the importance of CPR and the role of bystanders in saving lives can cultivate community responsibility and an altruistic culture. For trainers, comprehensive CPR training programs should be developed to cover not only technical skills but also address psychological barriers. This includes integrating simulation training to help bystanders overcome panic and self-doubt. To maintain public confidence and competence, regular review courses are recommended. The AHA’s guideline of retraining every two years can be adopted as standard practice. Training programs should also include components that provide psychological support and coping strategies to help bystanders manage emotional distress during emergencies. The healthcare system should invest in improving dispatcher-assisted CPR guidance, providing clear and step-by-step instructions to bystanders, which can significantly enhance their confidence and willingness to act. Ensuring sufficient availability of AEDs in public spaces and providing training on their use may also improve the effectiveness of bystander intervention. Additionally, collaboration with community organizations including schools, workplaces, and community centers to promote CPR training and awareness is recommended to initiate support for public participation in OHCPR, ultimately improving the survival rate of OHCA.
Conclusions
This review comprehensively identifies the factors determining public willingness to engage in OHCPR through systematic review and qualitative analysis. Public decision-making during OHCA is shaped by external situational factors, knowledge, and emotional and psychological distress. These factors determine public willingness to act and significantly influence behavior in emergencies. Future research should investigate strategies to optimize public training programs, enhancing their long-term effectiveness and sustainability. Targeted interventions, including culturally tailored educational materials and community-based initiatives, should address the specific needs of diverse cultural backgrounds and social groups. Future training should also incorporate psychological support and coping strategies to boost public confidence and ability to act.
Supplemental Material
Supplemental material - Public Participation Willingness in Out-of-Hospital Cardiopulmonary Resuscitation: A Meta-Synthesis of Qualitative Research
Supplemental material for Public Participation Willingness in Out-of-Hospital Cardiopulmonary Resuscitation: A Meta-Synthesis of Qualitative Research by Yuqiu Cheng, Wai I Ng, Chunzhi Zhang, Hongjun Liu, Ruxuan He, Ting Chen, Jiaqi Liang, Zeya Shi in International Journal of Qualitative Methods.
Footnotes
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Major Scientific Research Project for High-level Talents in Health Care of Hunan Province, “Evidence-based Evaluation of the 'Hunan Model' Practice and Effect of Public First Aid Education”, R20230722; Project of Hunan Provincial Finance Department, Hunan Finance Department Instruction [2022] 75, Research on the Construction of Pre-hospital Emergency Warning Response Model for Elderly Patients with Cardiovascular Diseases, 2050205; Project of Hunan Provincial Finance Department, Research on the Construction of a Smart Emergency Rescue Model Based on One-button Emergency Call for Integrated Response of Cerebrovascular and Cardiac Diseases, 2050205.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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