Diffusion of cardiopulmonary resuscitation training to chinese immigrants with limited english proficiency.

Abstract

Cardiopulmonary resuscitation (CPR) is an effective intervention for prehospital cardiac arrest. Despite all available training opportunities for CPR, disparities exist in participation in CPR training, CPR knowledge, and receipt of bystander CPR for certain ethnic groups. We conducted five focus groups with Chinese immigrants who self-reported limited English proficiency (LEP). A bilingual facilitator conducted all the sessions. All discussions were taped, recorded, translated, and transcribed. Transcripts were analyzed by content analysis guided by the theory of diffusion. The majority of participants did not know of CPR and did not know where to get trained. Complexity of CPR procedure, advantages of calling 9-1-1, lack of confidence, and possible liability discourage LEP individuals to learn CPR. LEP individuals welcome simplified Hands-Only CPR and are willing to perform CPR with instruction from 9-1-1 operators. Expanding the current training to include Hands-Only CPR and dispatcher-assisted CPR may motivate Chinese LEP individuals to get trained for CPR.

Full text

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Hindawi Publishing Corporation
Emergency Medicine International
Volume 2011, Article ID 685249, 8 pages
doi:10.1155/2011/685249
Research Article
Diffusionof CardiopulmonaryResuscitation Trainingto
ChineseImmigrantswithLimitedEnglishProficiency
MeiPo Yip,1Brandon Ong,1ShinPingTu,1DevoraChavez,2Brooke Ike,2IanPainter,2
Ida Lam,3StevenM. Bradley,2GloriaD.Coronado,4andHendrikaW.Meischke2
1Division of General Internal Medicine, School of Medicine, University of Washington, 325 9th Avenue, Seattle, WA 98104, USA
2Department of Health Services, Northwest Center for Public Health Practice, 1107 NE 45th Street, Seattle, WA 98105, USA
3Family and Youth Services, Chinese Information Service Center, 611 S Lane Street, Seattle, WA 98104, USA
4Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, Seattle, WA 98109, USA
Correspondence should be addressed to Mei Po Yip, yipm@u.washington.edu
Received 28 September 2010; Accepted 5 January 2011
Academic Editor: Walter Mauritz
Copyright © 2011 Mei Po Yip et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cardiopulmonary resuscitation (CPR) is an effective intervention for prehospital cardiac arrest. Despite all available training
opportunities for CPR, disparities exist in participation in CPR training, CPR knowledge, and receipt of bystander CPR for certain
ethnic groups. We conducted five focus groups with Chinese immigrants who self-reported limited English proficiency (LEP). A
bilingual facilitator conducted all the sessions. All discussions were taped, recorded, translated, and transcribed. Transcripts were
analyzed by content analysis guided by the theory of diffusion. The majority of participants did not know of CPR and did not
know where to get trained. Complexity of CPR procedure, advantages of calling 9-1-1, lack of confidence, and possible liability
discourage LEP individuals to learn CPR. LEP individuals welcome simplified Hands-Only CPR and are willing to perform CPR
with instruction from 9-1-1 operators. Expanding the current training to include Hands-Only CPR and dispatcher-assisted CPR
may motivate Chinese LEP individuals to get trained for CPR.
1.Introduction
In the United States, out-of-hospital cardiac arrest continues
tobeanimportantpublichealthproblem.Cardiopulmonary
resuscitation(CPR),inuseforfiftyyears,isthemosteffective
intervention for pre-hospital cardiac arrest [1–4]. Being an
integral part of the “chain of survival,” high-quality CPR
can improve out-of-hospital survival rate [5]. CPR can be
effectivelytaughttolaypersonsasaninterventionforout-of-
hospitalcardiacarresttoinitiateresuscitationand“buytime”
in the early minutes after cardiac arrest before the arrival of
emergency medical services. It is estimated that one life is
saved for every 24–36 persons who receive bystander CPR
[2, 6].
Public CPR training and instruction has been offered
to the general public in different ways. Most notably are
formal classes conducted by the American Heart Association
and the Red Cross, fire departments, workplaces, schools,
and dispatcher-assisted CPR delivered by 9-1-1 operators at
the time of the cardiac arrest. Despite all of these available
opportunities, the proportion of citizens trained to perform
CPR is small and many are unfamiliar with bystander CPR
[7–9]. Studies have shown that CPR training does not reach
desirable target populations in large numbers [10–12]. The
recent new guidelines provided by the American Heart
Association to include Hands-Only CPR expands current
strategies to disseminate CPR training [13]. Modification of
CPR by eliminating mouth-to-mouth ventilation, which is
often perceived to be difficult to perform and, for some,
possiblyembarrassing,maymakeCPRmoreaccessibletothe
public and encourage more people to get trained.
One of the goals of CPR training is to increase the num-
ber of citizens capable of performing CPR, and thus increase
the rate of bystander CPR. However, surveillance data have
also identified certain communities that have persistently
low rates of bystander CPR [14]. Studies have demonstrated
a racial difference in those receiving bystander CPR. In
a study investigating racial differences in out-of-hospital

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1. Knowledge
exposure to the
innvoation and
know how the
innovation works
2. Persuasion
develop an
attitude towards
the innovation,
either positive or
negative
3. Decision
engages in
activities that
lead to a choice
to adopt or reject
the innovation
4. Implementation
put the innovation
into practice
5. Confirmation
seek
reinforcement or
reverse the
adoption decision
Perceived characteristics of
the innovation:
Relative advantage
Compatibility
Complexity
Trialability
Observability
•
•
•
•
•
Figure 1: Five stages in the innovation-decision process.
cardiac arrest, less bystander-initiated CPR may contribute
to the difference in survival between black and white victims
[15, 16]. Hispanics are less likely to receive bystander-
initiated CPR than non-Hispanics [17]. Latinos, when
compared to African Americans and Caucasians, have the
lowest rate of receiving bystander CPR [18]. The bystander
CPR rate in Asians has not been reported. However, in
a study to understand socioeconomic factors influencing
bystander CPR, neighborhoods with increased percentages
of Asian residents and linguistically isolated households were
associated with lower rates of bystander CPR [19]. Most
people trained in CPR are more likely to be from younger
age groups, higher socioeconomic status, higher education
levels, and speak English as a first language [10, 20–22].
Weiner et al. reported disparities in the knowledge of basic
life support between whites and Hispanics [22]. A recent
study indicated that Asian Americans have lower rates of
CPR training than whites [23].
Nationally, among Asian-American subgroups, Chinese
Americanshavethehighestproportionofindividualsreport-
ing speaking English less than “very well” [24]. Forty-five
percent of the Chinese population living in Washington State
reported they “spoke English less than very well” [25]. Access
to CPR training, which is usually conducted in English,
is likely to be less available to limited English proficiency
(LEP) communities. People with limited skills in English
havedifficultyunderstandingwrittenandverbalinformation
and, therefore, are not often reached by English educational
materials or media-based campaigns using video, Internet,
or television [26]. We have not found any published
studies investigating the diffusion and dissemination of CPR
training in LEP communities.
Theoretical Framework. This study is guided by Roger’s
theory of diffusion. Diffusion is the process in which an
innovation is communicated through certain channels over
time among the members of a social system [27]. According
to Rogers, an innovation is an idea, practice, or object that is
perceivedasnewbyanindividual.Itdoesnotmatterwhether
or not that an idea is “objectively” new as measured by the
lapse of time since its first discovery [27]. The innovation-
decision process is an information-seeking and information-
processing activity in which an individual learns about the
innovation and makes a decision to adopt or reject it. As
described by Rogers, it is sequential and occurs over time,
consisting of a series of different actions (Figure 1). Informa-
tion exchange occurs in the five stages among members of
thesocialsystemthroughdifferentmassmedia,interpersonal
communication networks, and interactive communication.
An individual evaluates the innovation based on the new
information, shared attitudinal influences, and need for
behavioral change.
Knowing the existence of innovation is the first stage of
the innovation-decision process. With respect to CPR, an
individual in this stage learns about “innovation” (i.e., CPR)
either because of a need (e.g., job requirement) or passively
(e.g., passing by a billboard which promotes CPR). “Persua-
sion”isthesecondstageoftheprocessinwhichanindividual
develops a favorable or unfavorable attitude toward the
innovation. Unlike the first stage which focuses on “know-
ing” the innovation, the persuasion stage focuses on how
an individual “feels” about the innovation. At this stage,
perceivedcharacteristicsoftheinnovationdeterminetherate
of adoption. These characteristics include relative advantage,
compatibility, complexity, trialability, and observability [27].
In this study, we examine attributes of the innovation-
decision process that influence the adoption or rejection of
CPR. For example, we would like to understand how the
concept of CPR is introduced to LEP individuals. How do
Chinese LEP perceive CPR? What are the factors influencing
decisions to get trained? Where and how do Chinese LEP
obtain information about CPR training? Are Chinese LEP

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Emergency Medicine International3
receptive to performing CPR with instruction? Have Chinese
LEP heard of Hands-Only CPR?
2.MaterialsandMethods
2.1. Recruitment. We conducted five gender-matched focus
groups in Mandarin and Cantonese between December 2009
andApril2010.AdultChineseLEPmenandwomenlivingin
Seattle,Washingtonwererecruitedbyconveniencesampling.
The use of focus groups is an effective qualitative method to
seek opinions, values, and beliefs in a collective context that
provides insights into participants’ opinions and experiences
through group interaction [28, 29]. They have also been
used with culturally and linguistically diverse populations
[30–32]. Participants were recruited from the Chinese
Information and Service Center (CISC), a community-based
organization that provides cultural orientation and social
services to immigrants. Chinese adults aged 18 or above who
self-reported speaking English “not well” or “not at all” were
invited to participate in the study. We welcomed individuals
who had or had not received CPR training to participate
in the discussion. The goal of recruitment is to achieve
homogeneity in background (i.e., Chinese LEP) rather than
attitude (i.e., toward CPR training). Participants signed
informed consent forms and provided basic demographic
data prior to the focus group discussions. Participants
were offered an honorarium as a token of appreciation for
their time and were served light refreshments. All focus
groups were conducted in the participants’ native dialect.
Each focus group consisted of 8–10 participants and the
discussion lasted for about 1.5 hours. Table 1 shows an
example of questions based on the innovation-decision
process.
The first author, who is bilingual in English and Can-
tonese, conducted all focus groups with the assistance of a
trilingual interpreter (English, Mandarin, and Cantonese).
The discussion started off with a question “Have you heard
of CPR?” If all participants were not aware of CPR, the
facilitator explained by saying “Cardiopulmonary resuscita-
tion (CPR) is an emergency life-saving method to restart a
person’s heart. It consists of manually pushing up and down
on a person’s chest to pump their heart until more advanced
medical care is available.” The facilitator invited those who
had been CPR trained to share the meaning of CPR to the
group. We also showed a short video clip of Hands-Only
CPR to help participants visualize the CPR procedures. All
focus group discussions were tape recorded, translated, and
transcribed verbatim. An independent trilingual translator
(English, Mandarin, and Cantonese) first listened to the
Chinese audio recording multiple times and then performed
the translation and transcription. Transcripts were checked
against the tapes for accuracy.
Transcripts were analyzed by content analysis guided
by the innovation-decision process. The development of
the initial code book was based on these five stages and
the perceived characteristics of innovation. Two members
of the research team independently reviewed the transcript
and applied the codes to phrases written in the transcript.
Table 1: Examples of focus group questions based on the innova-
tion-decision process.
ConstructsQuestions
(1) Do you know what CPR is?
(2) Are you trained with CPR?
(3) Would you know if a person needed
CPR?
(4) Does whether or not you would perform
CPR depend on the particular situation?
(5) What motivates you to get trained for
CPR?
(6) What are your feelings towards CPR?
(7) Are any of your friends or family
members CPR trained?
(8) Do you know where to go to learn CPR?
(9) What way of learning CPR sounds best
to you?
(10) If you were to call 9-1-1 for help and
you said that someone wasn’t breathing, the
emergency operator would give you
directions for doing CPR. What could the
9-1-1 dispatcher say that would motivate
you to do CPR?
(11) Have you heard of “Hands-Only” CPR?
Knowledge
Persuasion
Perceieved
characteristics of
innovation
Decision
Implementation
The reviewers then met to discuss the content of each
transcript, codes applied, and any new information. Dif-
ferences of opinion were resolved through discussion and
consensus. The codes were then compared and similar codes
were clustered to form categories. Coding categories were
refineduntilalldatawerecodedintoexhaustiveandexclusive
categories [33].
3.Results and Discussion
3.1. Study Group Characteristics. Forty-six men and women
participated in our study. All were born outside the US
first-generation immigrants with nearly two-thirds having
lived in the US less than 10 years. More than 60% of
the study participants had attained more than 10 years of
education but only one-third is currently employed. Most
participants were married and lived with family. Table 2
shows the demographics of the study participants.
3.2. CPR Knowledge. To our surprise, the majority of
participants were not familiar with CPR. When introduced,
participants demonstrated some understanding of the basic
CPR concept. For example, the majority identify when CPR
is needed and that CPR can save lives. However, no one was
able to describe how CPR works. Of all the participants, only
six (13%) were CPR trained. Half of them received training
because of job requirements whereas the others received
training at a church or a community-based organization
for various reasons. CPR was offered and made available
to participants rather than the individual actively pursuing
opportunities to get trained. Except for those who got
trained, none could name organizations commonly known

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to offer CPR classes, like the Red Cross. The unpopularity of
CPR among the LEP Chinese community was described by a
participant:
“I think many Chinese here do not know how
to call 9-1-1 and they don’t know what to
expect from 9-1-1 [dispatcher]. Also, most of us
don’t know what CPR is. High school students,
Chinese immigrants for those who are in their
thirties to fifties don’t know. They have never
learned that [CPR]. I think over 80–90% of us
don’t know what is CPR. If we can make it more
popular, it would be good to every one of us.”
3.3. Relative Advantage of Performing CPR. Even though, to
most participants, being a good samaritan is consistent with
their values and beliefs, many would hesitate to actually
perform CPR in an emergency. Some participants preferred
calling 9-1-1 to starting CPR. Participants perceived greater
benefits of calling 9-1-1 than performing bystander CPR
which would result in a better outcome. Participants are
not confident in performing CPR. Worries about doing CPR
improperly, which could cause further harm, and the lack of
understanding of the role of CPR in the chain of survival
impedes LEP individuals from initiating CPR. Focus group
participants have different views on what should be done:
Participant A asked:
“Is dialing 9-1-1 [versus performing CPR] the better
way to do?”
Participant B replied:
“Sometimes it may be too late [delay performing
CPR].”
“It is true.” agreed participant C.
Participant D objected, “I think we should call 9-1-
1 first. Ya...the best way to do is to call 9-1-1. If
that person has no response and you perform CPR
on him, he may accuse you of wrong doing after he
regains his conscious. I just afraid of situation like
this. That’s my worry. I think calling 9-1-1 is the best
way.”
“Yes. Call 9-1-1 first since we are not professional. At
least we are covered. Then we try our best to help. I
think this is the way to go,” said participant D.
Participant E responds, “Yes. I never learn and don’t
knowwhattodo.Ihavenowaytoofferhelp.Iwillsee
if there is anyone stop by and ask for his assistance. If
there is no one around, I just wait until 9-1-1 people
come.”
3.4. Persuasion: Favorable Attitude toward CPR Certification.
With only a handful of participants trained, many of the
discussions were carried on by those who were not familiar
withCPRtraining.Whentold,manyparticipantsfavoredthe
idea of certification. They felt being certified would protect
them against possible legal liability in the future and that
Table 2: Study population characteristics (n = 46).
Sociodemographic variables
Gender
n (%)
17 (37%)
29 (63%)
15 (37%)
31 (67%)
3 (7%)
38 (83%)
2 (4%)
1 (2%)
2 (4%)
44 (96%)
2 (4%)
11 (24%)
35 (76%)
28 (61%)
18 (39%)
9 (20%)
6 (13%)
30 (65%)
1 (2%)
42 (91%)
4 (9%)
7 (15%)
39 (85%)
6 (13%)
40 (87%)
Male
Female
≥65
<65
Single
Married
Widow
Divorced
Other
China
Taiwan
≥10
<10
≥10
<10
Full-time
Part-time
Unemployed
Retired
Yes
No
Yes
No
Yes
No
Age
Marital Status
Place of birth
Length of time living in US
Years of education
Employment
Live with family/friends/relatives
Prior experience calling 9-1-1
CPR trained
certification permits the bystander to perform CPR and that
they are qualified to do so. Participants felt they were more
likely to perform CPR if they are certified. The issue of
certification is revealed through the discussion:
Participant A:
“At least we showed some knowledge [trained for
CPR]. Besides [learning the skill], getting a card or
piece of paper, writing down that you had completed
the course. If worst comes to worst, you have the card
to prove you have been trained.”
The other participant responds, “Yeah, I feel more
confident. It makes a difference. Here in US we talked
about the certificate all the time. Even an electrician
hasacertificate[license].Itwouldmakemefeelmore
comfortable and confidence doing CPR.”
Puzzled, one participant asked “I want to ask if one
does not have the card-can we still perform CPR?”
3.5.ComplexityofCPRProcedure. Thetwobiggestchallenges
confronting LEP participants who have not been trained
are the procedure itself and the possibility of causing
further harm. Some participants felt rescue breaths are more
difficult to perform than chest compression. Others were

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Emergency Medicine International5
not comfortable performing rescue breathing, particularly
to a stranger. Several female participants felt embarrassed
performing the mouth-to-mouth breathing on a male vic-
tim. Others worried about hygiene and the possibility of
contracting infectious diseases. As for chest compressions,
there were concerns about breaking the victim’s ribs when
pushing too hard, especially with children or the elderly:
one participant said,
“Idarenottoofferhelp[doingCPR]asImightbreak
hisrib.Youmaymakethingsworse.Thisisnotgood.”
Another participant elaborates further,
“Maybe he will recover [without intervention]. But
because you do the compression incorrectly, you may
actually cause further harm. You may even cost his
life! It makes me feel bad if that happens.”
ManyparticipantsfeltitisimportanttomastertheCPRskill.
Competency is critical for a participant to apply CPR confi-
dently in the future. Participants are eager to learn correct
hand position, how to locate the heart, depth of chest com-
pression, as well as of compression rate. To be competent,
practice is the key:
Participant A:
“We must practice. We can’t just learn by watching.”
PerhapstherationaletostresspracticeisbecauseCPRisalife
saving measure; therefore, one should take it seriously and
diligently. As one participant said:
“We have to master the key points. Learning without
practice means nothing. You have to master the skill
well since it is a life-and-death issue. Otherwise, how
can you do that right [to the victim]? You don’t have
the confidence. One have to [make sure] master the
skill first before rescue other people.”
3.6. Process of Implementation: Learning CPR through Dis-
patcher Instruction and Hands-Only CPR. Other ways to
learn CPR is through dispatcher instruction when calling 9-
1-1 or through the recently introduced Hands-Only CPR, a
simplewaytoperformthislifesavingskill.Ingeneral,partic-
ipants welcomed both alternative methods. One participant
said,
“I think it does not matter if the method you use
[standard versus Hands-Only CPR]. We just use
whatever method that is more effective to save peo-
ple’s life.”
There are advantages to each method. Hands-Only CPR was
accepted by the majority of participants because of it does
not involve rescue breathing. One participant said,
“It [Hands-Only CPR] reduces the embarrassment
of mouth-to-mouth ventilation. We don’t have to be
afraid of [mouth-to-mouth ventilation]. It is more
convenient.”
Agreed by another participant,
“Itismorehygienic.Youdon’tneedtoblowwithyour
mouth.”
Dispatcher-assisted CPR provides another opportunity for
individualswhohadneverreceivedtrainingtoperformCPR.
With guidance, many participants said they are willing to
do CPR. However, participants feel more confident in per-
forming CPR if they have prior knowledge. A participant
shared,
“I am sure I will be very nervous. I will try to keep
calm. I will press the speaker phone so I do not need
to hold the phone, it will waste my time. I will listen
and follow his instruction to do CPR. I will try. I wish
I could help. It is better than not helping.”
Participant also shared what the dispatcher can do to help
perform CPR:
“If you guide me going through the process [CPR]
which I have no idea, the first thing to do is that you
mustspeakmylanguage.Then,youhavetoexplainto
me what we will be doing, why we are doing so and
what we are going to achieve. I will feel confidence
to follow if you tell me these. If you just tell me what
to do without telling me why, I don’t know whether I
am doing it right or not. You tell me step by step and
I will follow. Just like a student follows the teacher’s
instruction:simple, step by step.”
3.7. Decision to Learn CPR: The Motivation Behind It. Few
participants in our focus group had seriously considered
gettingtrainedforCPR.Themajorityoftheparticipantswho
hadbeentrainedreceivedtrainingasajobrequirement.Only
one participant said she voluntarily went to training because
of her aging husband. Many thought there was no strong
urge or incentive to learn CPR. Time, cost, and language
barriers are other factors affecting LEP individuals’ intention
to receive training. For those interested, getting prepared is
the greatest motivation.
“I think the more you learn, the better you will be.
Especially the knowledge [CPR] we talk about. We
may come across this anytime, anywhere then we
can apply what we had learned [CPR] to help other
people. If we don’t know about this [CPR], there is
no way I can help,” said one participant.
“Though I never use it, but at least I know how
to respond in times of need,” another participant
replied.
Another participant who had received training said,
“Well, when it comes to reality [situation that require
him to perform CPR]. I am not sure whether I will
help. At that time [enroll in CPR training], I thought
thiswillbenefitmyfamilyinemergency.Idon’tknow
what is CPR but thought it might be good to learn.”