"A study published in 2020 found that the existing 'one-size-fits-all' approach to CPR training is insufficient" (Dobbie et al., 2020)

Research shows that immediate bystander CPR in the incident of an out-of-hospital cardiac arrest can more than double the chances of survival. As a willingness and confidence to initiate and deliver effective bystander CPR primarily depend on prior training, it’s perhaps unsurprising that communities with higher training rates have higher rates of bystander CPR and more successful outcomes. However, growing evidence from international studies is identifying that racial and ethnic disparities in survival for OHCA are apparent when compared to white community counterparts, with lower incidences of bystander CPR a notable factor. This highlights the importance of widening CPR training for diverse communities.

The potential causes for this are multi-faceted and subject to ongoing study but include deficits in community awareness, language barriers during emergency calls, public awareness and access to CPR training and defibrillation, variances in emergency medical services (EMS) response times and access to quality post-resuscitation care.

In this article, we’ll be focussing on the evidence that lower incidences of CPR training tend to occur within minority ethnic groups. We’ll investigate why CPR training is engaging less with diverse communities and how we, as a society, can work together to strengthen access to CPR training across communities of all backgrounds.

What is the Current Situation?

The rates of CPR training and BLS awareness are notably lower in communities with a more significant minority ethnic demographic. An article published by the NHS Race & Health Observatory reported that their director, Dr Habib Navqi, has called for increased uptake in CPR training among people from minority ethnic backgrounds in the UK.

The NHS Race & Health Observatory found that 26% of people from ethnic minority backgrounds when surveyed, believed that a cardiac arrest and a heart attack are the same things, while 33% weren’t confident as to whether they are the same or different. Furthermore, 47% of people from these backgrounds had never received any training to help someone experiencing a cardiac arrest.

Understanding the Barriers

In order to engage greater numbers of people from all backgrounds in CPR and other BLS training, we need to understand the barriers to accessing bystander CPR training in diverse communities. Through discussions with Sylvie Seales, the lead for International Nurses at Dartford and Gravesham NHS trust and a first aid community BLS trainer, we sought to gain a better understanding of these issues. The conversations showed that minority ethnic groups are aware of the importance of CPR training, as well as the health repercussions of OHCA. So, what is it that’s restricting access to BLS training?

To better understand why CPR training is engaging less with diverse communities, we spoke with experienced first aid community trainers and healthcare BLS experts. They explained that a lack of accurate or inclusive advertising could be a significant factor in low engagement within these communities. Studies show that, across both commercial and public service advertisements, people engage more strongly and form deeper attachments with services and goods advertised in a way that reflects their community.

Those we spoke with explained that most CPR training advertising depicts Caucasian trainers carrying out CPR on Caucasian manikins, generally to Caucasian learners. It’s unlikely, they believe, that such publicity will be as effective in engaging minority ethnic groups as more representative advertising might be.

To delve further, we invited Dr Adam Boulton from the University of Warwick for an in-depth discussion on the barriers to bystander CPR training in diverse communities. Dr Boulton’s clinical and research work focuses on resuscitation and care of the critically ill, from their initial prehospital treatment to post-resuscitation and critical care management. Recently his research has been investigating and tackling health inequalities for OHCA patients. Dr Boulton indicated multiple possible reasons for the health inequalities and poorer access to community CPR and defibrillation amongst ethnic minority groups. These included poorer access to CPR training, cost of training, competing interests in daily life, mistrust of authorities, and language barriers.

A study published in 2020 found that the existing ‘one-size-fits-all’ approach to CPR training is insufficient. It went on to discuss similar points raised by Dr Boulton, with participants in the qualitative study highlighting that CPR training is “only one of 100 other things they have to worry about”, with others referencing environmental barriers such as fear of violence, financial struggles and mistrust of the police.

This was supported by a more recent paper conducted by Northumbria University in cooperation with the North East Ambulance Service. This research found that individuals from more affluent areas were more likely to be comfortable performing bystander CPR while urging future research to explore how this data intersects with characteristics such as cultural identity and ethnicity to influence a willingness to conduct bystander CPR.  

How Can We Help to Overcome the Challenges?

Sylvie Seales showing the correct hand position for CPR using a Brayden manikin
Sylvie Seales (right) showing the correct hand position for CPR using a Brayden manikin

A crucial part of such challenges is in the advertising and engagement strategies of local community education groups. By providing more representative publicity for CPR and BLS training, it’s likely that engagement from minority ethnic groups will increase.

Sylvie Seales, who is also an OSCE (Objective Structured Clinical Examination) Assessor, advocated that training be conducted at more accessible locations. She believes that this would start to break down the barriers to bystander CPR training in diverse communities. Her suggestions include venues such as schools and sports clubs that are inclusive, friendly and accessible to people of minority ethnic groups.

This begins to identify and challenge the broader issue referenced by Dr Boulton and others in the research; that of environmental and socioeconomic factors that restrict access to BLS training for less-represented communities. By ensuring training is conducted at accessible times and locations, these difficulties can, perhaps, start to be overcome.

Another important factor that Dr Boulton raised during our discussion was the necessity for more inclusive CPR training equipment, such as CPR manikins. He suggested there is a need for training and CPR manikins to reflect the communities they represent and that those most in need need access to high-quality CPR to save lives. This may help to better engage with ethnic minority groups and improve knowledge and training in CPR. This was reinforced by others we spoke to, who highlighted the importance of CPR trainers, as well as the equipment they’re using, being representative of the communities they’re trying to engage.

The Brayden OBI Solution

In an effort to support this push to overcome these challenges, Innosonian is proud to be launching the Brayden OBI. An anatomically accurate CPR training manikin that benefits from nasal and mouth features representative of a black adult male, OBI allows for inclusive and realistic ventilation training. This is something that Jeannie Walls, the Lead Resuscitation Officer at St. George’s Teaching Hospital, outlined to us as a key feature. After her time extensively trialling OBI, she cites that pre-existing ‘diverse’ manikins often feature only an alternative skin tone and not other anatomical accuracies. The Brayden OBI manikin aims to improve the outcomes from cardiac arrests among diverse communities and, so far, has been met with overwhelmingly positive responses.

Brayden OBI showing LED blood-flow display.
Brayden OBI showing LED blood-flow display.
Brayden OBI showing integration with Brayden Online via IOS tablet
Brayden OBI showing integration with Brayden Online via IOS tablet

Sylvie Seales expressed support for the use of a culturally African name for the manikin, as well as the ability for NHS trusts to more accurately represent the diverse communities they’re a part of. Meanwhile, the community trainer that we spoke to suggested that incorporating the Brayden OBI into their education programs would be received positively and would be likely to improve engagement from less represented communities.

If you want to find out more about the features of the Brayden OBI manikin or discuss the ways in which we’re supporting the spread of BLS training to minority ethnic groups, feel free to get in touch. 

Further Reading