Resuscitation 88 (2015) 48–51

Contents lists available at ScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

An “Intention-Focused” paradigm for improving bystander CPR

performance夽
Ashish R. Panchal a,∗ , Jessica Fishman b , Teresa Camp-Rogers c ,
Roksolana Starodub d , Raina M. Merchant e
a
Center for EMS, Department of Emergency Medicine, The Ohio State University Wexner Medical Center, USA
b
Department of Psychiatry, Perelman School of Medicine and Annenberg School for Communication, USA
c
University of Texas Health Science Center, Houston, TX, USA
d
Biobehavioral Research Center, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
e
Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Despite public education campaigns and a chest compression-only initiative, bystander cardiopulmonary
Received 29 September 2014 resuscitation (CPR) is provided in approximately 30–40% of out of hospital cardiac arrests in the United
Received in revised form States. Bystander CPR rates may not improve without addressing factors influencing bystanders’ proba-
15 December 2014
bility of performing CPR. We propose an “intention-focused” model for the bystander CPR performance
Accepted 15 December 2014
utilizing validated behavioral theory. This model describes a framework that may predict CPR perfor-
mance, with intention as the key determinant of this behavior. This model may provide specific targets
Keywords:
for strengthening the intention to perform CPR, which could lead to increased bystander rates.
CPR
Cardiopulmonary resuscitation © 2015 Published by Elsevier Ireland Ltd.
Bystander
Intention
Behavioral theory
Behavior

1. Strengthening intentions to perform bystander
cardiopulmonary resuscitation (CPR)
Many public health issues demonstrate significant improve-
ment when interventions are developed to change behavior. These
behavior change interventions have been most effective when
theory-based.1–4 Examples of this are seen in many areas of pub-
lic health including effects on tobacco abuse, use of condoms, seat
belts, sun protection and decreasing the spread of Human immuno-
deficiency virus infection/acquired immunodeficiency syndrome
(HIV/AIDS).3,5–9 Prior work in reducing the risk of acquiring HIV
demonstrated that group- and community-level HIV behavioral
interventions were effective in reducing the odds of unprotected
sex and increasing condom use.9 A theory-based approach could
also be applied in the development of interventions to increase the
performance of bystander cardiopulmonary resuscitation (CPR).
夽 A Spanish translated version of the summary of this article appears as Appendix
in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.12.006.
∗ Corresponding author at: 760 Prior Hall, 376 West 10th Avenue, Columbus, OH
43210, USA.
E-mail address: Ashish.panchal@osumc.edu (A.R. Panchal).
Despite efforts to improve bystander CPR training, the rate of
bystander CPR performed in the US is only 30–40%.10–13 The exact
etiology of this problem is unclear. However, it is known that indi-
viduals trained in CPR, when in the situation of an out of hospital
cardiac arrest (OHCA), only performed CPR in 35% of cases.14 This
low uptake suggests that CPR training alone may not be sufficient to
effect a change in bystander CPR rates. A comprehensive, system-
atic framework of the factors that affect an individual’s probability
of performing CPR may help to develop interventions that increase
bystander CPR.
The current approach to increasing CPR focuses on training
(e.g. self-directed learning or instructor-led courses). Although
the training may provide individuals with the skills needed,
this task-focused interventional approach may not be effective
at increasing one’s motivation to actually perform CPR. Dur-
ing traditional CPR training courses, the learner reads prepared
material prior to class to learn the basic concepts of CPR. This
is followed by a classroom course, which assists in acquiring
and testing their acquisition of CPR skills. The process focuses
on learning facts, skills acquisition and retention. However,
during this course, there are no evaluations of a learner’s inten-
tion of performing CPR or theory-based attempts to strengthen
his/her intentions. There is also no clear understanding of which

http://dx.doi.org/10.1016/j.resuscitation.2014.12.006
0300-9572/© 2015 Published by Elsevier Ireland Ltd.
 A.R. Panchal et al. / Resuscitation 88 (2015) 48–51
psychological factors most influence the strength of intention to
perform CPR.
A better understanding is needed of the strength of intention to
perform CPR and how this may vary across different populations.
Intention is an individual’s perceived probability of performing a
specific behavior, in this case CPR. Identifying if individuals have
strong or weak intentions to perform CPR could help determine
which modifiable factors influence intentions. This approach could
allow for tailored interventions for learners who have strong inten-
tions to perform CPR but may face barriers to acting on strong
intentions. Another approach can be developed for those with weak
intentions. If these fundamentally different behavioral barriers are
addressed in the training process, this could increase CPR perfor-
mance.
This evaluation seeks to direct the focus of CPR training on an
individual’s intention to perform CPR. In this perspective, behav-
ioral theory is applied to the performance of CPR with presentation
of a novel “Intention-focused” model of bystander CPR. The end-
point of the application of this model is (1) the ability to determine
the strength of intention to perform CPR among a population of
interest, (2) identifying modifiable factors which diminish a pop-
ulation’s ability to act on strong intentions, and (3) determining
the degree to which intentions to perform CPR are influenced by
perceived norms, attitudes, and self-efficacy concerning CPR.
2. Application of behavior prediction theory to CPR
performance
Within the field of social science, theory-based interventions are
known to be the most effective at changing behavior.1–4 According
to well-validated models (e.g., The Theory of Planned Behavior and
Theory of Reasoned Action), an individual’s behavioral intentions
capture their motivation to perform a behavior and serve as an
indicator of the effort individuals are planning to exert to perform
the behavior.15–17 These models posit a strong causal association
between intentions and behavior where changes in intentions are
followed by changes in behavior, given that the individual has the
skills to act and there are no environmental constraints to pre-
vent action. When individuals have the skills and ability to act on
intentions, evidence has demonstrated that interventions which
strengthen intentions promote change in behavior.8,18
A shared feature of these models is that behavior is guided by
“intention” which is defined as the readiness to engage in a par-
ticular behavior.19 Strong intentions are necessary to performing a
voluntary behavior, but they may not be sufficient.16,17
3. Intention focused model of bystander CPR
Applying an integrative model of behavioral prediction to the
behavior of CPR performance may help to better develop new
approaches for increasing CPR rates. The developed “intention-
focused” model is illustrated in Fig. 1. The key aspects of this model
include: (1) intention is a focus of the model and influences the
likelihood of performance of CPR; (2) beliefs serve as the determi-
nants of intention; (3) bystander characteristics are distal variables
rather than primary determinants of intention or CPR behavior; and
(4) accounts for the interplay of skills, environmental constraints
and intention to perform CPR.
The model first focuses on intention as a proximal determinant
of performing CPR. This allows for an individuals underlying beliefs
to determine strength of intention. Once defined, CPR performance
is then also affected by the skills needed to perform and whether
the environmental constraints are significant enough to prevent
action.
49
Second, the model recognizes that an individual’s intention to
perform CPR is determined by their beliefs. These beliefs are a bal-
ance of what each individual believes about the world around them.
From these beliefs, the individual generates their personal attitudes
about CPR (positive or negative), their perceived norms of society
(what people will think if they do not perform the behavior – i.e.
social pressure) and their perceived ability to perform the behavior
with a predictable outcome (self-efficacy).
Third, the model notes that the bystander characteristics (e.g.
age, gender, education, religion) are distal variables and play an
indirect role in determining intention to perform the behavior.
This is an important distinction since, as people with different
educational background may have divergent beliefs about some
behaviors, yet still hold similar beliefs about another behavior.
Thus, these distal variables (e.g., education level) are indirectly
related to behavior.
This model has the potential to shift the paradigm of bystander
CPR training to an “intention focused” approach which may assist in
the generation of behavior interventions that increase the perfor-
mance of bystander CPR. A primary endpoint associated with this
paradigm will be an increase in the intention to perform CPR, mak-
ing measurements of intention an important outcome in bystander
CPR research.
4. Applying the model: defining the determinants of
intention to increase CPR
Interventions generated from this model will be focused at
influencing the determinants of intention among those with weak
intentions. Prior work has demonstrated that there are at least
three primary determinants of intention (Fig. 1): attitude toward
performing the behavior, perceived norms concerning the perfor-
mance of the behavior, and self-efficacy with respect to performing
the behavior.16,19
The intention-focused model also recognizes that the determi-
nants of intention are functions of underlying beliefs. Importantly,
beliefs are potentially modifiable and are the ideal targets of theory-
based interventions designed to increase intention and change
behavior.19 The beliefs of import can serve as the basis for an inter-
vention’s message development.
Interestingly, demographic, personality, and other individual
difference variables (such as perceived risk) do not necessarily play
a direct role in influencing behavior and are thus conceptualized as
distal variables (Fig. 1). These are “background” variables because
they are often unrelated to beliefs about the behavior of inter-
est. Thus, there is no clear relationship between these variables
and any given behavior.20 In contrast to beliefs, these variables are
difficult or impossible to modify. For this reason, considering the
performance of bystander CPR, focus must be placed not on these
variables but on those which are modifiable and have an influence
on intention and behavior.
5. Future directions for the application of the model
The validity of the use of an integrative model of behavioral pre-
diction to develop behavioral interventions has been demonstrated
in other areas.6,9,21 Detailed meta-analysis have demonstrated that
manipulation of intention have an effect on behavior.21 Regarding
CPR specifically, future studies will require study designs to demon-
strate that (1) intentions to perform bystander CPR vary for
different populations; (2) they can be strengthened by targeting the
determinants of intention (the norms, self-efficacy and/or attitudes
that explain the most variance in intention for a specific sub-
population); and (3) that CPR performance is more likely among
those with both strong intentions and the skills and abilities to act.
50 A.R. Panchal et al. / Resuscitation 88 (2015) 48–51
Distal Variables
Bystander
Characteriscs
including socio-
Beliefs
demographics (e.g.
age, gender,
educaon, religion)
and personality
traits.
Self Efficacy about
Fig. 1. Intention-focused model for bystander CPR performance. In this model, intention is the proximal determinant of behavior, where changes in intentions are followed
by changes in behavior when individuals have the skills and ability to act. Abbreviation: CPR, cardiopulmonary resuscitation.
To this end, cross sectional population surveys may be conducted
to evaluate differences in the intention to perform CPR. From this,
subgroups can be identified which have strong or weak intentions
to perform CPR and evaluated for whether the bulk of their inten-
tions are explained by personal attitudes, perceived norms of the
subgroup, self-efficacy, or a combination of these. Interventions can
then be developed to target the specific determinants of intention
to perform CPR.
Three possible implementation strategies include (1) develop-
ment of different instructional materials for broad learning styles,
(2) development of online modules that are tailored to different
learners, and (3) specific sub-population based campaigns that
target learners. First, with the improved understanding of the
determinants of intentions, learning materials can be developed for
broad learning styles focused on the key determinants of intention.
For example, if self-efficacy is the largest determinant of inten-
tion, instructional material can incorporate a significant focus on
survivors of cardiac arrest to demonstrate the positive effect of
performing CPR. Second, on-line modules can be developed similar
to the above instructional materials, which are tailored to differ-
ent learners. This would allow directed teaching to learners based
on their population characteristics to facilitate improvement of
intention. Finally, understanding sub groups which have strong
and weak intentions to perform CPR can assist in development of
campaigns directed at strengthening sub-populations intentions to
perform CPR. This would allow communities to direct mass media
interventions to the specific variables influencing the performance
of CPR.
6. Conclusion
Increasing bystander CPR will have a significant impact on out-
comes from out-of hospital cardiac arrest. The intention-focused
model for CPR performance allows for an understanding of deter-
minants of lay bystanders decision-making. Interventions can then
be designed to target specific modifiable variables that can increase
the likelihood CPR performance.
Skills needed
to Perform CPR
Atudes
about
performing CPR
Perceived Norms Intenon
Performing
about to Perform
performing CPR CPR
CPR
performing CPR
Environmental
Constraints on
Performing CPR
E.g. Physical access
to the vicm
Conflict of interest statement
Dr. Merchant: Grant/research support: NIH, K23 Grant
10714038, Pilot funding: Physio-Control Seattle, WA; Zoll Medical,
Boston MA; Cardiac Science, Bothell, WA; Philips Medical Seattle,
Washington, Heartsine, Ireland. There are no other significant con-
flicts of interest or disclosures.
Acknowledgements
We would like to thank the American Heart Association
Resuscitation Research Working Group and the American Heart
Association Emergency Cardiovascular Committee for their contin-
ued support and assistance with this project.
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