Wasted Potential : Awareness of Basic Cardiopulmonary Resuscitation in the Sultanate of OmanA Cross-Sectional National Survey

Cardiopulmonary Resuscitation is a critical step in the chain of survival in out-of-hospital emergencies. Community awareness and knowledge of CPR is essential in improving survival of out-of-hospital arrests. The knowledge of the Omani community about CPR has not been previously assessed. Aim: This study aims to assess the knowledge and awareness of people in the Sultanate of Oman about CPR skills. Methods: This is a cross sectional survey that was carried out in five cities in the Sultanate of Oman from March to May 2014. The survey tool gathered demographic data as well as information about training, knowledge and awareness of participants about CPR. The survey was distributed among 1500 participants. Results: A total of 873 surveys were completed in this study which equates to a 58.3% participation rate. 62.7% of respondents were able to correctly identify the two main components of CPR as being chest compression and ventilation. However, the study found that 54.8% of participants indicated that they do not know how to perform CPR. More worrying, 59.9% believed that CPR is not indicated in a situation where a child has chocked and became unconscious. Conclusion: This study demonstrated worrying figures that the knowledge of how and when to perform CPR within the Omani community is suboptimal. Awareness of CPR should be a national priority given the rising rates of road crashes and out of hospital emergencies in the country. National initiatives in order to educate the public about the importance of CPR as a life-saving skill are dearly needed.


Introduction
Cardiopulmonary Resuscitation (CPR) entails the use of both external chest compression and artificial ventilation to maintain oxygenation and circulatory flow during a cardiac arrest [1].It is the mainstay of Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) along with defibrillation [2].CPR should be performed immediately on any person who has become unconscious and is found to be pulseless [3].Assessment of cardiac electrical activity via rapid rhythm strip recording using community Automated Electrical Defibrillators (AEDs) can provide a more detailed analysis of the type of cardiac arrest, as well as indicating additional treatments required.In its full standard form, CPR comprises 3 steps performed in order; airway, breathing and chest compression.If done effectively, this could enhance the survival benefit of victims.
Several factors, including early CPR, can significantly improve chances of surviving a witnessed out of hospital cardiac arrest [4].For patients with cardiac arrest, survival rates and neurologic outcomes are poor, though early appropriate resuscitation (CPR), early defibrillation and appropriate implementation of post-cardiac arrest care, leads to improve survival and better neurologic outcomes [5].Targeted education and training regarding treatment of cardiac arrest directed at emergency medical services (EMS) professionals as well as the public has significantly increased cardiac arrest survival rates [6].Despite the benefits of the community CPR the incidence of bystander CPR is relatively low because the awareness of how to perform CPR is relatively inadequate among laid people [7].
In order to improve survival and neurological outcome, it is essential to promote bystander CPR [8].Various endeavors have been made to increase the number of people trained in resuscitation and to improve the quality of CPR.However, the proportion of CPRtrained persons in many communities remains insufficient, and the frequencies of immediate bystander CPR remain inadequate, even in developed countries [9].
According to the American Heart Association (AHA), four steps are usually involved leading to an effective bystander CPR.The first step is that the person recognizes that an event requires CPR.Secondly, they know and contact the emergency services number.The Proper help is dispatched by that service is the third step.Finally, CPR is commenced and continued until help arrives [10].The AHA also reports 5 critical steps to an effective CPR inside or outside the hospital.These are: minimizing interruptions in chest compressions, providing compressions of adequate rate and depth, avoiding leaning between compressions, and avoiding excessive ventilation [11].
The Sultanate of Oman is located on the south-eastern corner of the Arabian Peninsula occupying an area of 309,500 km 2 , the second largest in the Gulf Cooperation Council countries after Saudi Arabia.The country is divided into ten governorates and has a population of 2.77 million people according to 2010 census [12].It is a rapidly developing country which is undergoing significant changes in many aspects [13].This had led to an increase in the number of road traffic crashes victims [14].In addition, modernization meant that people living in Oman have developed illnesses of developed society's in particular ischemic heart disease [15].Oman is considered as one of the countries that has highest rate of road traffic crashes globally.The Omani Emergency Medical Services (EMS) is directed towards both trauma and medical emergencies [14].A study done in Oman in 2012 has suggested a pre hospital intervention e.g.public training of CPR that might improve the outcome of car accident victims [16].However, there has been no study that assesses the awareness of CPR in the Omani community.With the increase in road crashes and medical emergencies, the bystander CPR will become more important in Oman than ever before.

Methods
The study is a cross-sectional survey of a sample of people in the Sultanate of Oman from March to May 2014.The study utilized a questionnaire which included demographic data such as age, gender and socioeconomic status.Furthermore, the survey collected data on knowledge of CPR, sources of information about CPR, willingness to perform CPR, deterring factors from not willing to perform CPR and training of participants in CPR skills.The survey tool has 26 questions mainly of a tick box format and developed by researchers.The survey tool was initially validated and piloted among 20 people.The survey was distributed in five main cities in the Sultanate of Oman.The cities are Muscat, Sur, Ibri, Nizwa, and Salalah.Such cities cover the main populated areas in the country.
The study distributed 1500 surveys.This was carried out faceto-face at shopping malls and gatherings in the study locations named above.The number of surveys distributed is calculated based on assumed response rate of 50%.This sample size is estimated to provide sufficient power with a statistical significance to measure knowledge and awareness.Statistical significance was set at a P value of 0.05.
The results presented a descriptive analysis of all the variables collected.In order to assess the significance of differences in the variables a series of Chi-Square tests and the Fisher exact tests were used where appropriate.The Statistical Package for Social Sciences (SPSS) software (SPSS Statistics 12.1, for Windows ® , New York) was utilized in the data analysis.
The study has been reviewed and granted an ethical approval by the Sultan Qaboos University College of Medicine and Health Sciences ethics committee.

Results
There were 873 surveys returned from all regions of the Sultanate of Oman with a response rate of 58.3%.Table 1 shows the demographics of the survey responders.The proportion of male and female participants was similar.Omanis constituted 92.1% of respondents.Half of responders were full-time married or single employees.The highest level of education among respondents was high-school certificates, bachelors and diplomas respectively.The largest group of respondents earn around 500-1000 Omani Rials per month.
Table 2 showed the awareness of CPR in the Sultanate of Oman.62.7% of respondents recognized correctly that the two components of CPR are chest compression and ventilation.When asked to indicate whether CPR is warranted in a several possible scenarios, 61.7% of participants correctly indicated that they would perform CPR in an unconscious elderly man after a heart attack and 70.2% would do CPR in an unconscious and not breathing patient.However, 39.1% of respondents reported that CPR is not indicated in unconscious trauma patients.More worrying, 59.9% of participants thought that CPR is not indicated for a child who chocked on a piece of fruit and fell unconscious.Unfortunately, 54.8% of this survey participants reported that they do not know how to perform CPR.
When participants were asked to indicate what they would do first when responding to an unconscious man at home, 56.0% indicated that they would call the emergency national number (9999) and start CPR while waiting emergency services.Interestingly, in a car crash situation, 79.7% of survey responders failed to identify safety as the first step to ensure before attending to trauma patients.48% of responders thought the optimal location to perform chest compression is in the left side of the chest and 36.3%correctly identified the lower one third of the chest as the site of chest compressions.Furthermore, 33.4% reported that the optimal depth of chest compression is half of the chest diameter, and only 30.9% correctly identify the depth to be third of the chest diameter.Furthermore, only 26% of participants reported that the recommended chest to ventilation rate is 30:2.

Discussion
Cardiopulmonary Resuscitation (CPR) is a life-saving step in the chain of survival of out-of hospital cardiac arrest [15].Therefore, public awareness of CPR is critical in any society.Specific guidelines targeting CPR awareness has been published and practiced in many countries such as Japan, the United States, Australia and the United Kingdom [18][19].Many recent studies reported that CPR awareness and attendance of CPR training among the public is rising in many communities [18][19].This study attempted to measure CPR awareness among the lay people in the Sultanate of Oman.The study highlighted significant issues.
First, the survey found that 62.7% of respondents were able to correctly identify the two main components of CPR as chest compression and ventilation.This figure is similar to that published from a survey conducted in the United Kingdom in which 54% of participants were able to identify the two main components of community CPR [20].Another study from Saudi Arabia which was conducted among university students reported that only 31% of students were able to correctly identify the two components of CPR [21].Despite this relatively higher percentage of Omani people who identified the two components of CPR correctly, it is important to appreciate that more than half (54.8%) of this survey participants reported that they do not know how to perform community CPR.Further questioning of those participants who initially reported their ability to perform CPR, showed that more than 60% of them failed to correctly identify the location, rate and depth of chest compressions.This indicates false-sense of knowledge about CPR steps among people who think they know how to perform CPR.The awareness and knowledge was CPR as a term was also limited.
Furthermore, the reported rate (56%) of people who are willing to contact the emergency number before starting CPR is lower than that of other reported studies and indicative that many individuals are either reluctant to call an ambulance or do not know the emergency number.In comparison, in the Saudi study survey, 70% of participants knew the number to call in case of medical emergency [21].In addition, the UK study demonstrated that 55 % of their participants would call for the ambulance immediately after experiencing chest pain, with 74% of them stated that they would act within the first half an hour of having chest pain [20].This interaction between the bystander and the emergency service provider creates an opportunity for the provider to guide and aid the caller past many of their perceived barriers and fears to achieving successful bystander CPR [22].
Moreover, when surveyed individuals were asked about situations in which they will perform CPR, an alarming 59.9% and 39.1% failed to appreciate the need of CPR in an unconscious child who chocked on a piece of fruit and an unconscious trauma patient.
In the UK study, when participants were asked about what to do if encountered an unconscious person on the street, the majority stated that they would prefer to monitor and observe the patient while waiting for the ambulance rather than perform BLS [20].

Training and experience of participants of CPR
This study reported high rate of people with no formal training in CPR or no recent update of their previous training.It indicated that employment pre-requisite to be the most common reason for people to attend CPR training.Nevertheless, this figure seems to be higher than the 30% reported in the UK study in which 38% of them were in paid employment [20].This is also seen among Japanese as 35% of participants were trained for CPR [18] in which CPR training is a pre-requisite for driving license.This discrepancy between knowledge of CPR and being trained in it need to be eliminated by providing public training by legislators and law makers.This finding is consistent with a similar study carried out in Singapore in 2013 which found that although the majority of their respondents recognized the importance of CPR, a significant low proportion had any training in it [23].
Surprisingly, the majority of people who encountered a situation which they believed necessitated CPR did not carry it out due to perceived lack of knowledge with a low percentage stating that CPR was already started when they encountered the scene.In the UK study, it stated that individuals who received CPR training are three times more likely to consider starting chest compressions than those who were not trained.In addition, 61 % of participants trained in CPR reported that they would feel confident about performing CPR in an emergency situation [20].
Among the common source of public information regarding CPR, reading was the first in the list followed by media (TV) (48.5 %, and 34 % respectively).This would be crucial methods to be considered by the responsible authorities to promote CPR awareness among the public.It is also noted that in the UK and Saudi studies, TV was the main source for the public to gain knowledge about CPR [20][21].

Strengths and Limitations
This study is the first to assess the knowledge and awareness of the lay public in Oman regarding CPR.The study encompasses a representative sample of respondents from all regions in Oman.The study highlights a significant issue in which there is a great potential for community training and education.This study could be a baseline for any further well-structured educational programs in Oman to promote out of hospital CPR.This study has several limitations.First, the study is prone to inherent weaknesses of surveys such as self-selecting those participants who are interested in CPR training.Furthermore, the survey did not attempt to assess the actual skills of being able to perform CPR among those who reported being able to do so.Nevertheless, the study performed well for the purpose it is intended to.

Conclusion
This study assessed the awareness of Omani people in regard to community cardiopulmonary resuscitation.The findings of this study demonstrated lack of awareness of how and when to perform CPR among Omani people.The study highlighted a great potential for community-wide educational programs among all sectors in order to enhance CPR awareness for the greater good of the people living in Oman.In addition, government and private organizations in the country should be encouraged to include CPR training programs and refreshers as part of their employment development process.People should appreciate the importance of CPR as a lifesaving skill that is critical for any society.

Table 3
above showed the training and experience of participants in CPR.Almost half of responders indicated that reading is their main source of information about CPR.Of the total surveyed, 36.1% (n = 315) have previously faced a situation that they believed warranted CPR.Nevertheless, 63.8% of them did not perform CPR.When asked about the reasons for not performing CPR, 17.8% did not know how to do CPR and 12.1% indicated that they were other people before them performing CPR.Moreover, the majority of people surveyed (61.1%) reported having no formal training in CPR.Of those who had previous training, 39.1% had their training more than 3 years ago.When asked about the reason for having had

Table 1 :
Demographics of survey participants.

Table 2 :
Awareness of CPR in the sultanate of Oman.previous training, being an employment requirement (23.0%) is the common reason reported.Not knowing where to get information and training about CPR is the common reason reported for not having any previous training.Furthermore, 23.3% and 29.0% of non-trained participants reported that they don't believe CPR is essential skill or they do not have a time to attend training.

Table 3 :
Training and experience of the public regarding CPR in the Sultanate of Oman.