Bridging the Gap in CPR: Disparities in Layperson CPR Provision
Each year, more than 350,000 Americans experience Out-of-Hospital Cardiac Arrest (OHCA), or sudden stopping of the heart outside of the hospital setting. Nine out of ten people who experience OHCA die, but chances of survival can be significantly improved through bystander cardiopulmonary resuscitation (CPR). CPR is a life-saving action that maintains blood flow and oxygen delivery to the brain and other vital organs until professional help arrives. It is critical to start CPR as soon as possible; for each minute that passes without CPR, chances of survival drop by approximately 10%. Unfortunately, less than half of all OHCA victims receive timely CPR from bystanders—and sex, gender, race, and ethnicity factors come into play.
The Sex and Gender Disparity in CPR: A Global Issue
Women are less likely to receive CPR from bystanders than men, regardless of race, ethnicity, or location. In fact, Dr. Audrey Blewer and her team at Duke University found that no matter where they live in the U.S., women have a lower chance of receiving bystander CPR. This disparity exists worldwide, with similar findings in Asia and the Middle East. Addressing this gender gap is essential to improving survival rates for women experiencing OHCA. But, why does this gap exist in the first place? This seems to boil down to three main barriers: sociocultural, educational, and institutional.
Sociocultural Barriers:
- Gender roles and expectations: Societal norms influence who is expected to perform CPR, with assumptions that men are better suited for such tasks.
- Stigma and taboo: In some cultures, touching a stranger, especially of the opposite sex, is frowned upon.
- Fear of causing harm: Some bystanders may fear injuring a woman or facing accusations of inappropriate sexual behavior.
Educational Barriers:
- Misconceptions about women’s health: There’s a widespread belief that women are less likely to suffer from heart disease and this may not make people think about performing CPR on a woman.
- Inadequate training: CPR training often lacks scenarios or equipment that include women or female bodies, leading to uncertainty and hesitation in real-life situations.
Institutional Barriers:
- Policy gaps: Some institutions may have policies that inadvertently prioritize CPR training for men.
- Representation in training: Underrepresentation of women in leadership roles in CPR training programs can perpetuate these biases.
How Race and Ethnicity Factor into CPR Disparities
The rates of OHCA are higher within Black and Hispanic populations. This increased likelihood can be attributed to systemic health disparities. When considering socioeconomic status (SES), there is an association between lower SES and higher occurrence of OCHA. Multiple studies, including one in 2017 and another in 2020 by Dr. Blewer and her team at Duke, have found that regardless of where, in public or at home, an individual of a racial or ethnic minority suffering an OHCA is less likely to receive bystander CPR. In ethnic neighborhoods, oftentimes the initial CPR is not performed by a family member but instead by a first responder or emergency medical services. In predominantly White neighborhoods, the opposite is seen — family members have the knowledge and are the first to initiate CPR. Surviving an OHCA event starts with early recognition and rapid initiation of CPR. These key points elevate the value of teaching cardiopulmonary resuscitation within minority communities. When we look further into possible barriers for this lack of knowledge one theme strongly emerges: ACCESS! When we dive further, we can see that there are three specific components of access that contribute.
- Financial access: Many CPR courses require payment for not only the course, but the certificate that comes with it. The cost of the classes can vary depending upon the components taught within the course. When an individual must decide between paying to learn CPR or affording basic necessities like food or gas, the choice to learn CPR becomes less of a priority. Thus, those with pre-existing financial burdens face significant barriers impeding access to essential CPR classes.
- Geographical access: Many CPR classes are not held within Black and Hispanic communities. These courses often take place in locations that are not as easily accessible. By hosting an increased number of CPR trainings within racial and ethnic minority communities, the likelihood of individuals attending increases, helping to close the gap in CPR knowledge and practice.
- Time-related access: The length of time for a class can run from 2.5-6 hours depending upon the depth of information, including both CPR and first aid. With many in individuals of SES status juggling multiple jobs, it becomes difficult to attend a training that may be deemed non-essential. Since the time commitment alone can detract from earning indispensable income for some individuals, it may be hard to justify taking time away from their responsibilities despite the importance of CPR training.
Additional barriers to beginning bystander CPR have been noted to be fear of legal and financial ramifications, fear of discussing immigration status, and language barriers between a caller and dispatch.
It’s vital for community leaders, policy makers, and health organizations to advocate not only for this knowledge to be disseminated but also to ensure the accessibility of both this life-saving measure and adequate AEDs within public locations. By advocating for CPR education within these communities, both heart health awareness and emergency preparedness increases. Elevating the confidence of performing CPR leads to empowering not only the bystander, but also the overall community with the ability to act within a moment of crisis.
Taking Action with Current and Future Solutions
To close the sex, gender, race, and ethnicity gaps in CPR administration, we need to promote early and inclusive CPR training, use diverse training tools, and challenge societal norms through education and media. Here are some current and future actions that aim to improve survival rates for all OHCA victims, ensuring that all receive the life-saving care they deserve:
Early Intervention Training
One approach is to incorporate CPR training into school curriculums, starting from a young age. If taught through an inclusive lens, early education can help dispel stereotypes and promote more inclusive CPR practices. Research shows that even children as young as nine can effectively learn CPR techniques, which can be life-saving skills they carry into adulthood.
Establish Partnerships
Meeting potential lifesaving bystanders where they are can be impactful in disseminating training to people who may not otherwise receive it. By collaborating with health professionals, faith-based organizations, and community groups, expertise and resources can be leverages to enhance preparedness in all communities. Some examples of this principle in action include the work of students in the Duke PA Program as well as the Gen-Z-led nonprofit, GoodWorks.
Inclusive Training Materials & Equipment
Current CPR training programs often use manikins that do not accurately represent non-male anatomy, which can lead to bystander hesitancy when administering CPR to women. Using training tools like the PRESTAN Female Accessory, World Point Taylor, and Womanikin, which provide more realistic practice scenarios, can help prepare individuals to administer CPR to everyone, regardless of sex or gender.
Additionally, the use of training equipment of various skin colors can help promote inclusivity in many ways. Using multiple skin colors helps to normalize the idea that CPR training is applicable to all members of the community. Reflecting the diversity in our communities within the training helps to emphasize that the any person, regardless of race or ethnicity, could be a person in need of CPR. Having the opportunity to learn and practice CPR on mannikins that are of various skin colors can help remove a potential mental barrier that may cause a person to delay care when an emergency is occurring in real time. It is important to normalize that skin color does not affect, change, nor negate any of the primary steps within the 4-link chain of survival. The opportunity to discuss health disparities, particularly the rates of OCHA within Black and Hispanic communities, becomes an open conversation within the training. Most importantly, using various skin colors allows for trust to be built within the Black and Brown communities because it displays an outward symbol of recognition, helping to promote both equity and inclusivity in a vital component of health education.
Inclusivity in CPR training also includes using neutral language in training materials and ensuring equal representation of women and people of color in CPR-related media. Social media campaigns that highlight stories of women who have experienced OHCA can also challenge existing stereotypes and encourage more people to act when they see a woman in need of CPR.
Call to Action
Disparities in CPR administration based on sex, race, and ethnicity reveal deep-seated societal and institutional barriers to equitable healthcare. These disparities exist at both local and national levels with a differing balance of the contributing factors. As opposed to widespread, broad interventions, we advocate for place-based efforts rooted in location-specific needs involving tailored initiatives to improve access to timely CPR.
Intentional education, community outreach, and comprehensive training is necessary to dismantle any preconceived biases or stereotypes. Multiple community stakeholders, from schools and educational institutions, to local and national organizations must be involved to close these gaps. By promoting a culture of inclusivity that values all lives equally and addresses the fears and biases that impede timely action, we can improve survival outcomes for all people experiencing OHCA, regardless of background. The fight for inclusive care should leave no one behind, and it starts with ensuring that everyone is trained, prepared, and undoubtedly willing to act in the case of cardiac emergencies.
Audrey Blewer PhD, MPH and Janelle Bludorn MS, PA-C serve as Duke Family Medicine and Community Health faculty mentors for these students' work in understanding and addressing CPR disparities.