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Knowledge about cardiopulmonary resuscitation among foreign passport holders 1

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Knowledge & Attitudes Among English-Speaking Hong Kong Residents Holding a Foreign

Passport Regarding Bystander Response in Out-Of-Hospital Sudden Cardiac Arrest

Jon Forrest Holcombe

Emergency Medical Technician- Basic

National Safety Council (US) First Aid, CPR, & AED Instructor Candidate

[email protected]

Hong Kong International School

Emergency Medical Response Foundation

March 23, 2016

Word Count: 4,976


Abstract

The objective of this research was to look at the knowledge and attitudes of English-speaking

foreign passport holders residing in Hong Kong regarding bystander response in sudden

cardiac arrest emergencies. A mixed-method cross-sectional population based survey among

families that fit this demographic was undertaken at an international school in Hong Kong,

and were aged 16+. It was found that knowledge and attitudes regarding resuscitation and

bystander response in emergencies are greater and more positive among English-speaking

foreign passport holders in Hong Kong than they are among the local population. It is evident

that the foreign-passport holders see this topic as more important. This is most likely due to

cultural stigmas, values, and norms. However, the confidence level among those holding a

foreign passport is still extremely low (35.3% of respondents), and overall resuscitation and

situational knowledge is still lacking. Government and non-governmental organizations also

need to continuously promote resuscitation training and education, as well as subsidise it.

They should also explore diverse approaches to train and instill confidence in the population.

Enacting laws to protect bystanders and implementing a bystander response system would

increase bystander response rates, hence bridging the gap between the occurrence of the

arrest and the arrival of emergency medical services, and therefore improving survival rates.

Incorporating CPR into the secondary school curriculum as a mandatory graduation

requirement is also advised.

Key words: cardiac arrest, Hong Kong, bystander response, cardiopulmonary resuscitation,

knowledge, attitudes


Introduction

Cardiac arrest is the greatest public health epidemic facing our world today. In

essence, it is the number one cause of death globally, as the term can be used synonymously

with death.1,2, 36 Even more shocking is the survival rate from cardiac arrests occurring outside

a hospital, more formally known as out-of-hospital cardiac arrest (OHCA), in Hong Kong is

1.25% to 3.0%.3-7 This is well below the standards of other developed cities such as Seattle,

Washington in the United States which has an OHCA survival rate of 46%, the highest in the

world.35 This high rate of survival is explained by their strengthening of the chain of survival,

including the training of bystanders in Cardiopulmonary Resuscitation and defibrillation.

This large variance in survival rates globally is due is due to the fact that cardiac arrest

involves numerous disciplines and organizations, and therefore lacks ownership and

accountability in the medical community.36 Communities must analyze what links in the

chain of survival are missing and innovatively improve those links.

Medical analysis of sudden cardiac arrest

Sudden cardiac arrest (SCA) is a specific type of cardiac arrest that while exhibiting

itself the same as normal cardiac arrest once it has occurred, shows no symptoms before the

arrest.35 When an individual goes into SCA due to non-traumatic causes, the heart stops

beating normally, and most often enters a shaky, chaotic rhythm known as Ventricular

Fibrillation (VF).35 Non-traumatic SCA can be defined as a SCA not induced by events that

involve trauma or terminal illnesses.35 VF is is only correctable by prompt defibrillation, and

it cannot be corrected by Cardiopulmonary Resuscitation (CPR), or the hard and fast

compression of the chest, alone.35 As indicated by its name, death from SCA occurs suddenly

Knowledge about cardiopulmonary resuscitation among foreign passport holders 5and unexpectedly.10 It occurs instantly after the onset of symptoms, with chances of the

patient being resuscitated reduced 7%-10% every minute if left untreated.10 Within 4-6

minutes after the onset of SCA brain death begins to occur.35 While the exact cause of a SCA

is often attributed to many factors, it can strike a person anytime, anywhere, and at any age.

In addition, while those with a history of heart disease are at greater risk, even a person who

seems healthy can go into sudden cardiac arrest without warning.

The chain of survival

In the minutes following an OHCA there are several actions, which, if implemented in

a timely manner, can significantly increase a patient’s chances of survival. These actions are

known as the “chain of survival.” They include action points such as early access to

emergency care, early Cardiopulmonary Resuscitation (CPR), rapid and effective

defibrillation, early advanced life support (ALS), and comprehensive post-cardiac arrest

care.1,8 The first step, “early access to emergency care,” involves recognizing the

unresponsiveness and not breathing as cardiac arrest and activating the local emergency

system.1,8 It is then extremely important for the person in cardiac arrest to receive CPR

followed by shocks from a defibrillator.1,8 Advanced life support provided by prehospital care

personnel such as paramedics should run parallel to the first three steps.1,8 ALS involves the

administration of medications to stimulate the heart to return to normal sinus rhythm (the

heart’s normal rhythm), as well other advanced procedures.1,8 Finally, the patient must be

transported to a hospital specializing in post-resuscitation procedures such as the therapeutic

cooling of the body to slow the dying process and allow for recovery.1,8 While every link in

the chain is vital to the holistic care and survival of a patient, early, high-quality CPR as

defined by the most current guidelines can double or even triple survival rates in patients

Knowledge about cardiopulmonary resuscitation among foreign passport holders 6suffering from OHCA.9,17,18 In a study conducted by J. Herlitz and his associates on OHCAs,

53% of patients indicated the rhythm VF within 4 minutes of their collapse.26 Bystander CPR

helped maintain VF, avoiding the hard-to-correct asystole rhythm (flatline).26

The occurrences and issues regarding bystander CPR in Hong Kong

While 58-72% of shockable OHCA are witnessed in Hong Kong3,5,25, and more than

40% of OHCA in Hong Kong occur in the home setting,11 the bystander CPR rate still

remains incredibly low at less than 20% compared to a potential 58-72%.12 It is estimated that

in Hong Kong, a city of over seven million, less than 20 percent of people are trained in

CPR.13-17 Yet even among those that are trained, a recent study indicates that their ability to

perform adequate CPR in a cardiac emergency is questionable.13

Reasons bystanders do not perform CPR in Hong Kong

Among those who have not been trained, it is reported that people are reluctant to do

so because of lack of time, interest, and access to a course.19-21,23 Other possible reasons

included the fear of infection, lack of confidence due to forgetting a technique, concern

regarding mistakes and hurting a patient, and the legal consequences of performing such

procedures.19-21,23 This attitude against performing CPR is present in those trained as well.7 In

a 2015 study of Hong Kong secondary school students, 44.3% of them either strongly agreed

or remained neutral on the statement that learning CPR is not necessary.22 Yet 83.3% of

students in the same study report a willingness to perform CPR, even if they lack training, in

a cardiac emergency.22 It is also predicted that implementing legislation in Hong Kong to

protect bystanders, acting within their training and with good intention, from legal action

taken against them could increase bystander response rates.27 Often bystanders are unwilling

Knowledge about cardiopulmonary resuscitation among foreign passport holders 7to perform CPR for fear of hurting the patient or of being sued. Such laws, known as Good

Samaritan laws, would most likely alleviate uncertainties regarding legal suits and encourage

more action in an emergency, and so lift another barrier in the way of a bystander wishing to

administer lifesaving care.27

It is likely that the most common reason bystanders do not intervene in a cardiac

arrest emergency in big cities, such as Hong Kong, is due to what psychologists refer to as

“bystander problem.”34 The theory was developed by psychologists Bibb Latane and John

Darley.34 In their study they staged emergencies in a variety of situations.34 What they found

was that people who were alone were often almost two to three times as likely to respond to a

neighbor in distress compared to those participants who were in groups.34 Latane and Darley

found that the reasoning for this lies in the diffusion of responsibility.34 When one is in a

group, one assumes that someone else will act in an emergency, and if no one does, one’s

brain convinces itself that there is not really a problem.34 If one is alone, one-hundred percent

of the responsibility is on that person in an emergency situation, so they feel compelled to

act.34 Ironically, the fewer bystanders you have on an emergency scene, the more likely

someone is to act. This is what is assumed to be the case in Hong Kong: a diffusion of

responsibility at public emergency scenes.

Public Access Defibrillation

Another important aspect of the chain of survival is early defibrillation. As stated

previously, CPR and defibrillation work congruently to correct VF. Public Access

Defibrillation (PAD) is the movement for bystanders and staff in public places to be trained

in AED use and to respond to cardiac emergencies with a defibrillator.28,29 While Hong Kong

matches other countries in the availability of AEDs, the PAD rate in Hong Kong is still only

Knowledge about cardiopulmonary resuscitation among foreign passport holders 80.168%28, and the average time to first defibrillation shock is 14.25 minutes.37 The reasoning

behind these two figures may be that the responder has no knowledge of the AED’s location,

and in addition, the responder may feel afraid of using the AED incorrectly, consequently,

fearing legal consequences.28

The ideal defibrillation time is less than 6 minutes after the collapse.29 In fact, 75% of

Ventricular Fibrillation rhythms can be corrected if defibrillation is received within three

minutes combined with CPR.32 Automatic External Defibrillators (AEDs) are extremely easy

to use, and AEDs are meant to be used by everyone, not just medical professionals.

Hypotheses, bias, and assumptions

Despite CPR being a 50 year old tested and proven procedure that requires little

training, no equipment, and very little money, it is still not performed often enough in cardiac

emergencies.30 The same can be said for AED use. However, with cultural stigmas in place

regarding legality, infection, and an overall mindset of minding one’s own business, it is not

surprising that most Hong Kongers aire on the side of doing “no harm without any action

including CPR.”6,31 While some research has investigated the knowledge and attitudes of the

Hong Kong population towards Cardiopulmonary Resuscitation among local Cantonese-

speaking populations,13,15,22 this study will take a holistic approach to examine the attitudes

and knowledge regarding full bystander involvement in saving lives amongst English-

speakers who do not hold a Hong Kong or British National Overseas (BNO) passport. This

study will investigate, through online survey, attitudes towards the current situation in Hong

Kong, CPR and AED knowledge, attitudes towards CPR and AED use, demographics, and

willingness to join a citizen response group. The research may be affected by bias due to the

author working for foundation that aims to raise cardiac arrest survival rates in Hong Kong

Knowledge about cardiopulmonary resuscitation among foreign passport holders 9and currently trains the public in CPR. It is assumed that people will have some sense of

moral and ethical obligation that might affect their responses to the survey and not give an

accurate indicator of how they would respond to a cardiac arrest emergency if they actually

encountered one.

The hypothesis is that foreign passport holders in Hong Kong will be lacking in

knowledge of and positive attitudes towards the issue and response to the emergency;

however, they will still have a higher knowledge and better attitudes than the local

Cantonese-speaking populations.

Methods & Ethics

Population, sample, and limitations

The survey population consisted of English-Speaking Hong Kong residents of

domestic households aged 16+, who hold a foreign passport, yet hold a Hong Kong resident’s

identity card. Based off the 2014 data, the number of Hong Kong Identity Card holders

(residents of Hong Kong not holding a Hong Kong or British National Overseas passport)

was 694,196.33 Data regarding the proportion of this population over the age of 16 was

unavailable, and the study was also limited by the time restraints placed by the College

Board; consequently, it was not possible to collect all the responses needed to gain a high

confidence level for such a large population. Therefore, a random selection focus group was

formed from over 100 participants based off English-speaking foreign passport holders at an

international school in Hong Kong aged 16 and above. The response rate was approximately

30%. The data has no external validity, nor is it possible to generalize any of the data

collected to a larger population.

Knowledge about cardiopulmonary resuscitation among foreign passport holders 10The instrument

The survey was a 61-question mixed method, cross-sectional, population-based study

conducted in a standardized survey format via Google Forms using fixed-alternative

questions, as well as free response follow-up questions developed from previous surveys

done in Hong Kong such as “Public knowledge and attitudes towards cardiopulmonary

resuscitation in Hong Kong: telephone survey,”13 “CPR knowledge and attitudes among high

school students aged 15-16 in Hong Kong,”22 “Knowledge of cardiopulmonary resuscitation

among the public in Hong Kong: telephone questionnaire survey,”15 as well as a

comprehensive literature review. The survey was written in English. It took approximately 15

minutes to complete, and was pilot tested prior to the survey launch to the public. Due to the

similarity of the questions to the other previous surveys, it was determined that the Content

Validity Index (CVI), a score to rate items’ relevance to the underlying construct, was 0.95.

The questionnaire contained 4 sections based off our review of the relevant literature and the

“2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and

Emergency Cardiovascular Care.”1 The first section addressed socio-demographic variables

such as gender, age, education level, and occupation, while the second section highlighted

medical demographics such as investigations into training received (or lack thereof) and

family history of heart disease. The third section asked participants to reflect on their

knowledge of and attitudes toward CPR. The final section will collect data regarding the

respondents attitudes towards the current situation in Hong Kong and their thoughts about

joining a citizen response group.

Knowledge about cardiopulmonary resuscitation among foreign passport holders 11Data collection procedures

Participants were selected from a list of high school students at an international school

in Hong Kong. The list was blocked into grades 10, 11, and 12, and then every third person,

if they held a foreign passport, was selected along with one or both of their parents. In

addition, some teachers and administrators were selected to participate. They were emailed

and told they would be entered into a drawing for a HK$100 Starbucks gift card as incentive

for participating in the survey. They were given a 7-day period to complete the Google

survey. They were given strict instructions not to use the internet to assist in the completion

of a survey. Those who did not reply to the survey were labeled as non-response.

Ethics

Eligible participants were given an overview of the study, and consent was obtained

(Figure 1). It was clear that participation was voluntary. Confidentiality of the data was

guaranteed. There was no personal information collected beyond the optional provision of the

respondent’s email address to be eligible for a HK$100 Starbucks gift card as incentive. All

data was destroyed after analysis. The study will seek recognition from the Institutional

Review Board from Hong Kong International School.


Figure 1. Screenshot of the voluntary participation agreement

Results

Social & medical demographics

In the survey we conducted, among the 34 respondents, 55.9% were female and 10 different

passport countries were represented. These countries were India, Canada, The United States

of America, The United Kingdom, Sweden, Australia, Japan, Korea, the Philippines, and

Ireland. The respondents’ ages ranged from 16 years old to between 65-74 years old, and

Knowledge about cardiopulmonary resuscitation among foreign passport holders 1355.8% had some post-secondary school education. The highest level of education in our

sample was PhD. The demographic data from our sample is not able to be compared to the

general population of Hong Kong due to the lack of government statistics regarding foreign

passport holders. Of our sample’s tenure in Hong Kong, 58.8% of the respondents had lived

in Hong Kong for 8 or more years, which classifies them under Hong Kong law as

“permanent residents.”38 For respondents who had lived in more than one place, the mean

population of the largest city they have lived in was 3.6 million. 55.9% of the respondents

had children, which is most likely explained by the focus group conducted through the

school. The mean number of people living in each household was 3 (including domestic

help). The largest religious population within our sample was Christianity at 26.5%. None of

our respondents had heart disease; however, 14.7% were at risk. In addition, 14.7% also had a

family member who has or did have heart disease.

Cardiopulmonary resuscitation training characteristics

97.1% of the respondents believed it is necessary to learn CPR; however, only 69.7% of them

had received CPR training. This is still higher than the 21% of Cantonese-speaking Hong

Kong residents who have received CPR training.13 Of the 23 respondents who had received

training, 36% of those respondents received training more than 2 years ago, and 47.8% of

those trained only practice once every 3 years. Only 21.7% of respondents practiced at the

recommended rate of once every six months. 66.6% of those who had taken training also

reported that it was because of their job or education system’s mandatory requirements, all

others trained took it out of interest. 70.83% took a 5-hour course (compared to a possible 12

hours), most commonly through their country’s version of the Red Cross.


For those who are not training, 9.1% said it was due to the training being too

expensive, 27.3% said they are unaware of where to get training, and the majority (54.5%)

said they had no time or that it was not on their list of priorities. However, almost all others

(90%) have thought about getting CPR trained. For those who have had CPR training, 75% of

those were at risk for heart disease or had a family member who had/has heart disease. 63.2%

of the females of had received training, 80% of males had received training. Of those who

had children, 80% had CPR training. Of those holding Asian passports or those who were

permanent residents of Hong Kong, only 66.7% had received CPR training compared to

76.9% of those non-Asian passport holders who have lived in Hong Kong for 7 or less years.

Attitudes towards resuscitation

Two of the respondents had performed CPR on a live patient; however, 64.7% of all

respondents reported not feeling confident that they could provide proper medical care in an

emergency. 61.8% reported that they would attempt to perform CPR on a stranger, which is

higher than the 57% of Hong Kong passport holders who said they would.13 All the

respondents reported that they would attempt to perform CPR on a family member, regardless

of their level of training. 60.6% of respondents reported not being confident using an AED,

most commonly citing the reason for this being lack of training. Only 38% of those who

responded positively in our study about performing CPR on a stranger were permanent

residents of Hong Kong. There was no significant correlation between willingness to perform

CPR on a stranger and the population of the last city the respondents lived in. 19% of those

who said they would help a stranger did not have CPR training, and 7 respondents who had

been trained in CPR said they would not help a stranger. In addition, 71.43% of those who

said they would perform CPR on a stranger practiced their skills at least once every year, if

Knowledge about cardiopulmonary resuscitation among foreign passport holders 15not more. All but one of the respondents who reported being confident in their ability to

respond to an emergency had been trained in CPR. 75% of those practiced at least once a year

if not more. 13 of those who had received CPR training reported not being confident.. In

addition 75% had received their training in the past year. Only 21.43% of those aged 16-18

reported being confident. There was no strong gender correlation.

Resuscitation knowledge review

More than 88% of respondents were able to recognize if a person needed CPR: 27 out

of 34 respondents knew how to check if a patient was unresponsive, and 82.4% of

respondents knew how to check for breathing; however, 32.4% could not recognize agonal

breathing. Agonal breathing is the gasping sound that some cardiac arrest patients exhibit

shortly after the onset of their symptoms. 73.5% of respondents were able to identify the most

common airway obstruction known to cardiac arrest patients, and all the respondents knew

how to mitigate that risk using the head-tilt, chin-lift technique. Despite the high number of

respondents that had received CPR training, only 55.9% of respondents could give the correct

ratio of chest compressions to ventilations, and even less, 52.9%, knew the correct

compression rate per minute. 88.2% of respondents knew what an automated external

defibrillator is, 91.2% knew when they could use it, and 76.5% knew how to operate it in

special circumstances. Those who had received training scored on average higher than those

without training (Figure 2).


Figure 2. Comparison of percentage of correct answers on resuscitation knowledge review section between

those who have had resuscitation training and those who have not.

In addition, there was also a downward trend correlating the years since the last training class

and the scores on the knowledge assessment (Figure 3).

Figure 3. Average percent score on the resuscitation knowledge review by how many years ago the respondent

got resuscitation training.

Knowledge about cardiopulmonary resuscitation among foreign passport holders 17The effect course length (5 or 12 hours) had no significant effect on knowledge.

Knowledge & Attitudes Regarding Surroundings and the Hong Kong Situation

To determine overall knowledge regarding the general situation in Hong Kong,

participants were asked another series of questions (Figures 4 and 5).

Figure 4. Questions regarding the situation in Hong Kong (part 1).


Figure 5. Questions regarding the situation in Hong Kong (part 2).

76.5% of participants reported not knowing where the closest AED was to their home,

but for those who did know where it is, it seemed to be an average of about 100 metres away.

However, a higher percentage (44.1%) indicated that they knew where the closest AED was

to their work, most of them indicating it was around 5 minutes away. 11.7% of foreign

passport holders did not know the correct phone number to call in an emergency in Hong

Kong. 60.6% of people reported that they are more likely to use the Hong Kong Fire Services

Ambulances over St. John’s Ambulance; however, 47.1% of people reported preferring to

transport someone themselves during an emergency to a private hospital. 64.7% of people

report being satisfied with emergency services in Hong Kong citing their own personal

Knowledge about cardiopulmonary resuscitation among foreign passport holders 19experiences to reference the FSD as “quick, efficient, highly trained, and well equipped”

Among those satisfied, however, 95.24% of these people did not know the average response

time for the HKFSD Ambulances (12 minutes).37 Of all the respondents, 91.2% of people did

not know the average response time for the HKFSD Ambulances. For those who were not

satisfied, all of them cited “response time” as the main factor. 41.2% of respondents did not

know that your survival chances fall 7-10% every minute once cardiac arrest has occurred,

and 91.2% of respondents did not know the cardiac arrest survival rate in Hong Kong. 50% of

respondents reported that they would join a volunteer citizen response network that pledged

to respond to emergencies and provide care to bridge the gap between the occurrence of an

emergency and the arrival of an ambulance. Those who did not wish to join cited reasons

such as “lack of transportation, privacy, lack of training, worry about performing a wrong

task, time, liability, and travel.” One respondent even stated that everyone should “ascribe the

situation to systems and infrastructure. These are bigger than a citizen group.” 35.29% of

those who said they would participate in such group said they would not assist a stranger on

the street, and the same number of would-be program participants lacked resuscitation

training. 12 out of the 17 people who said they would participate in the program said they

lacked confidence in their ability to respond to an emergency. 8% of those who did not want

to participate in such a program said they were confident in their ability to respond to an

emergency and they would also be willing to attempt to resuscitate a stranger on the street.

Discussion & suggestions

The hypotheses stated in the introduction were confirmed. The majority of people in

this study had received CPR training (69.7%), which is significantly higher in contrast to the

general local population at an estimated 21%.13 This number is close to the CPR training

Knowledge about cardiopulmonary resuscitation among foreign passport holders 20percentage in several westernized cities and countries such as Australia (58%), Poland (75%),

and Washington in the United States (79%).13 This is most likely due to the fact that the

majority of our foreign passport holders hailed from non-Asian countries, hence having been

exposed to more rigorous community CPR training programs. Unfortunately, this large

number of CPR-trained foreign passport holders is not indicative of the population of Hong

Kong as a whole, so a more extensive community CPR training program should be

implemented in Hong Kong.

Among the sample of foreign passport holders, the most common reason for not

getting CPR training was lack of time or interest (54.5%). Other lesser noted reasons were

not being sure of where to attend a course and course expenses. The main reasons that the

respondents took CPR training was for their job or education system’s mandatory

requirements (66.6%). Few people took a CPR course out of interest

These issues can be mitigated in part by self-instruction compression-only CPR. Some

studies show that video self-instruction is as good as traditional classroom instruction.25,26

This method also allows for a lower cost and a flexible time frame. In addition, public

advertisements regarding how to do CPR, and also information as where to get traditional

training may prove useful. Subsidies for compression-only CPR training, as is often popular

in countries like the United States,7 would also be very valuable in encouraging more people

to get trained. As of yet, there are very few free CPR courses in Hong Kong. However,

perhaps the best solution to overcome the issue of citizens not getting trained in CPR is to

begin mandatory CPR training as part of the Hong Kong secondary school curriculum. This

ensures that every graduating secondary school class is equipped with the tools to save a life.

After several generations of this training, the majority of the Hong Kong population will be

trained in resuscitation, and survival rates from cardiac arrest will be improved. In addition,

Knowledge about cardiopulmonary resuscitation among foreign passport holders 21making CPR mandatory in workplaces is an important strategy to increasing bystander

knowledge and response. Due to the fact that all participants said they were willing to

perform CPR on a loved one, family may also be used as a motivator to increase CPR

training rates.

The level of resuscitation knowledge in our sample was low. The overall average test

score rate amongst those with training was 76.75%. Those without prior training scored even

lower. Most of the answers could have been deduced through common sense; however, it was

seen on some questions that those with first aid training tended to overthink and over-

medicalize situations, while those without training went for the common sense, correct

answer. Once again, this supports the fact that CPR is easy for everyone to learn.

While CPR is easy to learn, it does require some skill set, and based off the scores

obtained on the knowledge section of the survey (although knowledge cannot be equated with

clinical skills), these respondents would mostly likely be unprepared or incompetent

performing CPR in real situations. It is important to note, however, that performing CPR

without 100% accuracy is better than doing nothing at all. It was also made clear that

knowledge decreases or is forgotten over time, and so a refresher course or practice session

has been recommended every six months to in order to maintain skills.24 If it is not possible

to receive practice every six months, one should not go longer than 2 years without

reinstruction.24 Training institutions should seek to remind former trainees to renew their

training at these time intervals, and offer them incentives to do so. While the effect course

length had on confidence and knowledge is negligible, 12 hour courses offer more

personalized instruction with an instructor, thereby increasing confidence. Some of the

respondents were trained more than 5 years ago, which means that different resuscitation

Knowledge about cardiopulmonary resuscitation among foreign passport holders 22guidelines were in place when they received training, possibly giving some reason to their

lower scores as well as stressing the importance of continuing education in the realm of CPR.

The survey unintentionally did not explore why people refuse to perform bystander

CPR due to a neglect to add the appropriate question into the survey before sending it out to

the sample; however, the assumptions and reasoning behind this were discussed in the

literature review. Information such as this may be crucial to changing the mindsets of

bystanders and warrants further study.

Conclusion

Knowledge and attitudes regarding resuscitation and bystander response in

emergencies are greater and more positive among English-speaking foreign passport holders

in Hong Kong than they are among the local population. This is most likely due to cultural

stigmas, values, and norms. However, while there are some differences, at the core of it all,

more similarities are seen. The confidence level among those holding a foreign passport is

still extremely low (35.3% of respondents), and overall resuscitation and situational

knowledge is still lacking. It was also made clear that knowledge decreases or is forgotten

over time and so a refresher or practice has been recommended for those trained every 2

months if possible, and not exceeding 2 years.

Government and non-governmental organizations also need to continuously promote

resuscitation training and education, as well as subsidise it. Diverse approaches to confidently

train the population should also be explored. Enacting laws to protect bystanders and

implementing a bystander response system would increase bystander response rates, hence

bridging the gap between the occurrence of the arrest and the arrival of emergency medical

Knowledge about cardiopulmonary resuscitation among foreign passport holders 23services, and thereby improving survival rates. Incorporating CPR into the secondary school

curriculum as a mandatory graduation requirement is also advised.

This research is relevant in the face of Hong Kong having the lowest cardiac arrest

survival rate in the developed world. If survival rates are increased, not only will cardiac

arrest care improve, but all emergency care for all conditions will improve.35 If a system can

perform well in the worst and most complicated of all emergencies, cardiac arrest, it can

perform even better in all other, less serious emergencies.35 The conclusions and data from

this study should be able to supplement the data collected on the Cantonese-speaking

populations to implement the discussed solutions to raise survival rates in Hong Kong. In the

future, this research could be expanded to include both populations in one study that has a

high confidence interval and collects data via telephone survey regarding health habits,

psychological information, as well as reasons for not performing CPR. As more data is

collected, programs can be created and adapted to solve this dynamic and multifaceted issue.

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Knowledge about cardiopulmonary resuscitation among foreign passport holders 29APPENDIX

Survey: introduction & voluntary participation agreement

Knowledge about cardiopulmonary resuscitation among foreign passport holders 30Survey: social demographics



Survey: medical demographics



Knowledge about cardiopulmonary resuscitation among foreign passport holders 35Survey: resuscitation knowledge review


Knowledge about cardiopulmonary resuscitation among foreign passport holders 37Survey: societal knowledge review

Knowledge about cardiopulmonary resuscitation among foreign passport holders 38Survey: submission confirmation

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