Keep The Safety Net Intact Through Refresher: Resuscitation Intention In Chinese Lay- Rescuers Decreases With Time Via Mediation Of Theory Of Planned Behaviours Determinants But Not Knowledge—A Cross-Sectional Survey

Keep The Safety Net Intact Through Refresher: Resuscitation Intention In Chinese Lay- Rescuers Decreases With Time Via Mediation Of Theory Of Planned Behaviours Determinants But Not Knowledge—A Cross-Sectional Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Keep The Safety Net Intact Through Refresher: Resuscitation Intention In Chinese Lay- Rescuers Decreases With Time Via Mediation Of Theory Of Planned Behaviours Determinants But Not Knowledge—A Cross-Sectional Survey Victor C. W. TAM, Nelson C. Y. YEUNG, Anthony Wai Leung KWOK This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7093960/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Out-of-hospital cardiac arrest (OHCA) threatens thousands of lives each year inHong Kong (HK). While early cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED) are essential to improve OHCA survival, local bystander resuscitation attempt rates were low. To encourage bystander resuscitation and establish a safety net in the community to save lives, the ‘Intention-focused’ training approach based on the Theory of Planned Behaviour (TPB) is advocated, aiming to boost lay-rescuers' willingness to perform Basic Life Support (BLS) by addressing attitude, subjective norms, and perceived behavioural control (PBC). However, refresher courses in Hong Kong still focus on revisiting resuscitation knowledge and skills. This article aimed to investigate the association between time since last training and BLS intention, and the potential mediating role of knowledge and Theory of Planned Behaviour (TPB) determinants. Methods: A cross-sectional online survey of 678 non-healthcare adult lay-rescuerswas conducted in 2022 using snowball sampling. Participants were categorised by years since last training: trained within 1 year (n=289), 1-2 years (n=141), 3-5 years (n=129), and >5 years (n=119). The Intention to Deliver BLS scale was used. Mediation analysis was conducted using SPSS PROCESS Macro. Results: Years since the last training were negatively associated with attitude (B=-0.10; P< .001), subjective norms (B=-0.18; P< .001), and PBC (B=-0.31; P< .001). Higher attitude (B=0.36; P< .001), subjective norms (B=0.24; P< .001), and PBC (B=0.45; P< .001) scores were associated with higher BLS intention. Knowledge was negatively associated with time since last training (B=-0.54; P< .001), but not significantly associated with BLS intention (B=0.02; P= .33). Mediation analysis revealed significant indirect effects of years since last training on BLS intention via attitude (B=-0.04; 95%CI, -0.06 to -0.02), subjective norms (B=-0.04; 95%CI, -0.07 to -0.02), and PBC (B=-0.14; 95%CI, -0.18 to -0.10), but insignificant for knowledge (B=-0.01, 95%CI; -0.03 to 0.02). The direct effect was insignificant (B=-0.02; 95%CI, -0.08 to 0.50), suggesting a full mediation. Conclusions: Resuscitation intention decreases with time through TPB determinants, but not knowledge. Comprehensive reviews of the current refresher strategy, focusing on knowledge and skill revisit, are warranted. Future research should focus on developing culturally-adapted 'Intention-focused' refresher pedagogies that address these psychobehavioural factors. Health sciences/Cardiology Health sciences/Health care Health sciences/Medical research willingness intention cardiopulmonary resuscitation automated external defibrillation lay rescuers Theory of Planned Behaviour attitude subjective norms perceived behavioural control knowledge Figures Figure 1 Figure 2 Figure 3 Background There are around 3.8 million people who experience out-of-hospital cardiac arrests (OHCA) each year around the globe, and only one in ten survives[ 1 ]. In Hong Kong (HK), the survival rate upon hospital arrival was alarmingly low, at 8.3%, with only 44.6% of victims receiving bystander cardiopulmonary resuscitation (CPR), and 1.9% undergoing bystander defibrillation by an automated external defibrillator (AED)[ 2 ]. While OHCA can occur anywhere in the community where healthcare professionals might not be around as first responders, CPR and AED training for community members are essential to facilitate timely bystander resuscitation to OHCA victims. This serves as a safety net in the community, enhancing the survival of OHCA victims[ 3 ]. Given that resuscitation skills and willingness could decay over time[ 4 – 6 ], certified lay rescuers are required to attend the refresher course and renew their certificates every two to three years in HK, Europe, and the United States[ 7 – 10 ]. Early bystander Basic Life Support (BLS), comprising CPR and AED, was significantly associated with the survival of OHCA patients [ 3 , 11 ]. Public CPR and AED courses, along with refresher sessions, are crucial for equipping and retaining community members with essential knowledge and skills. In addition, accumulating evidence has revealed the importance of addressing intention, or willingness, to perform CPR and AED as the key to successful bystander resuscitation. The European Resuscitation Council (ERC) initiated a new session discussing ‘the public willingness to perform CPR’ in its upcoming 2025 guidelines, addressing research gaps from the learner’s perspective in resuscitation educational research[ 12 , 13 ]. Besides, the American Heart Association (AHA) advocated the ‘Intention-focused model for bystanders’ to boost the bystander CPR rate[ 3 ], positing ‘Intention’ at the core of the lay-rescuer training strategy. The ‘Intention-focused’ model incorporated the Theory of Planned Behaviour (TPB), featuring three determinants: attitude, subjective norms, and perceived behavioural control (PBC)[ 14 ]. In addition to knowledge and skills, previous studies have shown that attitude and subjective norms are the strongest predictors of CPR intention, with the suggested model accounting for 51–57% of the variation in intention [ 15 , 16 ]. Besides, it has been highlighted that considering socio-demographics, training factors, and barriers associated with community willingness is crucial in layperson resuscitation training[ 17 ]. In HK, our team demonstrated that CPR and AED willingness were not associated with knowledge level but all TPB determinants[ 18 ]. Despite the current shift in focus to boost bystanders’ intention to initiate CPR [ 3 ], local refresher courses remained focused on revisiting knowledge and skills by repeated practice. Furthermore, it is unclear how the depletion of willingness since the last training was influenced by the cognitive and psychobehavioural variables. By understanding the potential mediating role of the TPB determinants on the decay of resuscitation intention over time, training institutes could optimise the refresher courses to boost lay-rescuers’ intention. This article aims to investigate the potential mediating effects of knowledge and TPB determinants on the relationship between the length of time since the last training and BLS intention among trained lay-rescuers. We hypothesised that (i) the years since the lasting training was negatively associated with attitude, subjective norms, PBC and knowledge; (ii) attitude, subjective norms, PBC and knowledge were positively associated with BLS intention; and (iii) years since the lasting training was negatively associated with BLS intention, mediated by attitude, subjective norms, PBC and knowledge. Figure 1 shows the proposed mediation model. Methods Study design and population This paper presents the secondary analysis of an online cross-sectional survey conducted in HK from December 28, 2021, to April 14, 2022, using snowball sampling on social media, including WhatsApp, Instagram, and Facebook. Ethics approval was obtained from the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (reference no: 158 − 21). The study was conducted in accordance with the Declaration of Helsinki. Inclusion criteria were (i) living in HK, (ii) understanding Chinese, (iii) aged 18–64 years, (iv) having been trained for a CPR/AED course, and (v) implied consent by survey completion. Excluding healthcare professionals, responses from 678 trained lay adults were extracted from 1449 valid responses for this analysis. This sample met the minimum sample size of 393 required for parallel mediation analysis[ 19 ]. Data collection and measurements Demographics, such as age and gender, were collected anonymously. Participants were asked whether they had ever received CPR or AED training. The number of years since the last training ( 5 years ago) was asked for those who have been trained. The Intention to Deliver BLS scale was used, which includes four sub-scales: (i)overall BLS intention, (ii)attitude, (iii)subjective norms, and (iv)perceived behavioural control measured in 15 items[ 18 ]. This TPB-based instrument was established and validated in 1449 community members in HK. Participants were asked to rate their intention, in case of an OHCA, to perform CPR and AED on two separate 5-point (0–4 points) Likert scale (Sample item: “I will perform CPR without hesitation on an unresponsive victim with no normal breathing in the community” ). The mean score of these two items was calculated to represent the overall BLS intention, which served as the dependent variable in this study [ 18 ]. Proposed mediators, including attitude, subjective norms, and PBC, were assessed using 5-point (0–4 points) Likert scales. The mean scores of items were calculated to represent the corresponding sub-scales. Attitude was represented by four items with good reliability (α = 0.77)[ 18 ]. Sample item: “CPR and AED are beneficial to an unresponsive victim” . Subjective norms were represented by five items with excellent reliability (α = 0.93)[ 18 ]. Sample item: “I believe that the general public expects me to perform CPR and use AED on an unresponsive victim” . Perceived behavioural control was represented by four items with an excellent reliability (α = 0.95)[ 18 ]. Sample item: “I am confident to perform CPR and use AED” . Knowledge, also proposed as a mediator, was represented by the number of correct answers out of eight multiple-choice questions regarding CPR and AED. Statistical analysis Data were analysed using IBM SPSS Statistics version 26 (SPSS Inc., Chicago, USA). Correlation between the intention to deliver CPR and AED was examined by Spearman’s rank correlation (ρ). Analysis of variance (ANOVA) with post-hoc Tukey’s range tests was used to compare the mean scores of variables across years since the last training. Correlations between the time since last training, the proposed mediators, and the BLS intention mean scores were examined by Pearson’s correlation ( r ). A p-value < 0.05 was considered statistically significant. PROCESS Macro was used to examine the mediating effects of knowledge, attitude, subjective norms, and PBC on the relationship between the years since last training and BLS intention. The mediation analysis was supplemented with 5000 bootstrap replications. A statistically significant effect was considered if the 95% bias-corrected CI did not include zero. Results Demographics and training background The majority of the respondents were female (52.1%), aged between 18 and 25 years (39.1%), attained a diploma or a bachelor’s degree as the highest educational level (64.2%), and earned less than HKD15001 (37.6%). For occupation, approximately one-third (33.3%) were students, another one-third (35.0%) were civilians, and the remaining one-third had various occupations. Regarding resuscitation training experience, over half of them received both CPR and AED training (64.0%). Most of the respondents received their last training in the past year (42.6%), while 17.6% of them trained more than 5 years ago. Table 1 summarises the characteristics of respondents. Table 1 Participant characteristics (N = 678) Demographic characteristics Frequency (Percentage [%]) Gender Female 353 (52.1) Male 325 (47.9) Age 18–25 265 (39.1) 26–40 222 (32.7) 41–64 191 (28.2) Educational level Secondary or below 110 (16.2) Post-secondary (includes diploma and undergraduate) 435 (64.2) Postgraduate (includes Master and above) 133 (19.6) Monthly income $ 60,000 74 (10.9) Training backgrounds Frequency (Percentage [%]) Training type Either CPR or AED 244 (36.0) CPR & AED 434 (64.0) Years since the last training Within 1 year 289 (42.6) 1–2 years ago 141 (20.8) 3–5 years ago 129 (19.0) More than 5 years ago 119 (17.6) Intention to deliver CPR and AED Over half of the respondents were willing to perform CPR (51.8%) and AED (54.7%), while more than one-fifth disagreed to perform CPR (21.2%) or AED (23.1%) (Fig. 2 ). A strong correlation was revealed between CPR and AED intention (ρ = 0.71; P < .001). Correlation between major variables Table 2 shows the descriptive statistics and correlation among variables. Years since the last training were negatively correlated with intention ( r =-0.33; P < .001), knowledge ( r =-0.52; P < .001), attitude ( r =-0.30; P < .001), subjective norms ( r =-0.33; P < .001) and PBC ( r =-0.45; P < .001). Knowledge and all TPB determinants were positively correlated with BLS intention ( r = 0.34–0.67; all Ps < .001). Table 2 Descriptive statistics and correlates of BLS intention and predictors among trained lay-rescuers (N = 678) 1 2 3 4 5 6 1. Time since the last training - 2. BLS intention † − .33*** - 3. Knowledge ‡ − .52*** .34*** - 4. Attitude † − .30*** .48*** .33*** - 5. Subjective norms † − .33*** .57*** .31*** .50*** - 6. Perceived behavioural control † − .45*** .67*** .44*** .45*** .63*** - Mean 2.12 2.47 5.50 3.44 2.76 2.44 SD 1.43 1.09 1.61 0.54 0.82 1.04 Cronbach’s alpha / .83 / .77 .92 .94 Footnote: † Highest score = 4 ‡ Highest score = 8 *** P < .001 BLS , Basic Life Support. For demographics, education level was not significantly correlated with BLS intention ( r = 0.003; P = .93). Being male ( r = 0.22; P < .001), older age ( r = 0.12; P = .002), higher monthly income ( r = 0.09; P = .02), and trained in both CPR and AED ( r = 0.37; P < .001) were significantly correlated with BLS intention, thus being included as covariates. Mediation analysis Predictors in the hypothesised model explained 51.9% of the variance in BLS intention ( R 2 = 0.519; F 9, 668 =80.15; P < .001) (Fig. 3 ). Three TPB determinants mediated the relationship between the years since the last training and BLS intention. Years since the last training were negatively associated with attitude (B=-0.10; se = .02; P < .001), subjective norms (B=-0.18; se = .03; P < .001), and PBC (B=-0.31; se = .03; P < .001). Higher attitude (B = 0.36; se = .07; P < .001), subjective norms (B = 0.24; se = .05; P < .001), and PBC (B = 0.45; se = .04; P < .001) scores were associated with higher BLS intention. Similarly, years in the last training were negatively associated with knowledge (B=-0.54; se = .05; P < .001); however, knowledge was not significantly associated with BLS intention (B = 0.02; se = .02; P = .33). The indirect effects from years since the last training to BLS intention via attitude (B=-0.04; se = 0.01; 95%CI, -0.06 to -0.02), subjective norms (B=-0.04; se = 0.01; 95%CI, -0.07 to -0.02), and PBC (B=-0.14; se = 0.02; 95%CI, -0.18 to -0.10) were significant. However, the indirect effect of knowledge was not significant (B=-0.01; se = 0.01; 95%CI, -0.03 to 0.02). The total indirect effect was significant (B=-0.23; se = 0.03; 95%CI, -0.29 to -0.18) while the direct effect was not significant (B=-0.02; se = 0.03; 95%CI, -0.08 to 0.50). Therefore, a full mediation was suggested. Discussion To the best of our knowledge, this is the first study to investigate the mediating role of the three TPB determinants on the relationship between lay-rescuers' CPR and AED intentions and the timespan since the last training, aiming to provide insights into boosting lay-rescuers’ resuscitation intentions during refresher training. The AHA has since advocated the ‘Intention-focused model for bystanders’ to boost the bystander CPR rate by addressing their intention and the associated factors[ 3 ]. Our findings revealed that the intention to perform BLS decreased over time since the last training, and this relationship was mediated by all TPB determinants. It is worth noting that although knowledge level decreased with time, it was not significantly associated with BLS intention. Weaving the safety net for OHCA victims High-quality bystander CPR and early defibrillation constitute the second and third rings in an adult chain of survival in an OHCA victim, which were significantly associated with the patient’s survival[ 3 ]. As OHCA can occur anywhere at any time, when healthcare professionals are not always available, CPR and AED training for laypersons could establish a safety net within a community to save lives. It was demonstrated that lay rescuers could perform CPR efficiently, and there is no difference in one-month survival with favourable neurological outcomes for OHCA patients receiving CPR by laypersons and off-duty healthcare professionals[ 11 ]. While previous studies have revealed the deterioration of skills and willingness to perform CPR[ 4 – 6 ], refresher courses play a crucial role in maintaining the readiness of bystanders to perform resuscitation and keeping this safety net intact. Knowledge revisit in refresher Local refresher courses currently focus on revisiting relevant knowledge and skills, rarely addressing lay-rescuers' intentions and psychobehavioural aspects [ 8 , 9 , 20 ]. Skills and knowledge are undoubtedly fundamental in CPR and AED training, but mastering them does not necessarily translate into intention and actions. This Know-Do gap was evident in a previous study, in which only 29% of respondents were willing to offer CPR, despite having recently completed the BLS course[ 21 ]. The current study revealed that, despite knowledge decreasing over time, it was not associated with BLS intention, reinforcing that ‘knowing it’ does not necessarily mean being ‘willing to do it’. However, inconsistent findings were reported in studies from Malaysia and China[ 15 , 21 , 22 ]. A positive association was apparently more prevalent among university students than older adults. It may be because the younger population tends to consider ‘correctness’ from a theoretical perspective during their student years, while older people are inclined to be driven by life experience and a sense of social responsibility [ 23 ]. Nonetheless, this finding urged a deep reflection on the proportion of revisiting knowledge in the refresher course, especially among older adults. TPB determinants as mediators While all three TPB determinants were significant mediators, PBC was the strongest predictor of resuscitation intention and the strongest mediation path compared to attitude and subjective norms. Perceived behavioural control was defined as the degree to which ones feel that s/he can control the performance of the behaviour [ 24 ]. It has often been confused with self-efficacy, which refers to the perceived capabilities in performing the specific behaviours [ 25 ]. While PBC could be correlated with self-efficacy, it is also a measure of how much one feels that external constraints possibly limit their control over action. Our findings were different from previous studies using TPB to predict resuscitation intention among college students in USA [ 16 ], university students [ 15 ] and civil servants [ 23 ] in mainland China, where attitude and subjective norms were the strongest predictors of CPR intention. There are two major differences between the current study and the existing research which might explain the discrepancies. Firstly, there were fundamental differences in modelling, which the current study investigated the relationship between intention and timespan since the last training, with three TPB determinants as mediators instead of independent variables. Perceived behavioural control appeared to have a stronger negative correlation with the timespan since the last training when compared to the other two determinants; therefore, it had a stronger mediating effect. Another plausible reason could be the distinct population of trained lay-rescuers in our study. While untrained persons might consider initiating resuscitation more by their intuitions or perceived civil responsibility, trained layman with prior skill training might be more aware that this is their decision to initiate resuscitation, and they might have propensity to considerate whether they can perform the skills well and the possible consequences if they choose to initiate resuscitation. Developing culturally-adapted ‘Intention-Focused’ pedagogy While the ‘Intention-Focused’ paradigm for bystander CPR training was first introduced in 2015[ 26 ], it has been limitedly adopted in HK. The model incorporated the TPB as the theoretical backbone, focusing on intention as the immediate determinant of performing CPR, with attitude, subjective norms, and PBC as the determinants of intention[ 14 ]. Bystander characteristics were considered ‘distal’ factors, together with the interplay of skills, environmental constraints, and intention to perform CPR. Previous studies have identified various common barriers and facilitators to bystander resuscitation, for example, overwhelming fear and distress, uncertainty about when CPR is appropriate, and inability to position the patient on a flat firm surface [ 27 – 29 ]. Some barriers may be regionally or culturally specific. For instance, Black or Hispanic victims were less likely to receive CPR in the US [ 30 ]. While female gender patients were, in general, less likely to receive bystander resuscitation, this barrier was expected to be more prominent in conservative cultural, social and religious norms of certain regions in Asia and Africa [ 31 ]. These barriers should be addressed and translated into a willingness to perform resuscitation through the TPB determinants during public training. Although AHA has advocated the ‘Intention-focused model for bystanders’ later in 2022[ 3 ], there were no comprehensive practical guidelines on how to integrate this concept into refresher training. It is reasonable not to have a one-size-fits-all training package as the resuscitation intentions of a community could vary significantly across regions [ 30 ]. Yet, enormous efforts are warranted to investigate the factors associated with laypersons’ CPR and AED intention and understand the local context in order to tailor effective, culturally adaptive training and refresher courses. For instance, fear of legal liability was rated as the top barrier in Hong Kong[ 18 , 32 ]. However, Good Samaritan Law is not in force, despite the majority (95.2%) of first-aid learners supporting its enactment [ 33 ]. Hong Kong follows the English common law, in which holding a layperson rescuer liable for negligence in a resuscitation attempt is generally cautious[ 34 ]. Discussing legal liability in a refresher course could acknowledge learners’ legal concerns, provide a better understanding of the legal context in HK, and thus facilitate them in making an informed choice of action. Regarding the format of the refresher, it was found that a problem-based approach, combined with simulation and debriefing, significantly outperformed traditional training in improving CPR performance[ 35 ]. Simulation realism could stimulate participants’ innate sense of social responsibility. Timely debriefing facilitates reflection on one’s preferences and considerations in a simulated OHCA crisis, fostering the exchange of ideas among peers and addressing collective concerns. The paradigm shift in current pedagogy demands not just the establishment of a lesson plan, but also the trainer's belief and competence in addressing psychobehavioural concerns and boosting laypeople’s intention to deliver CPR and AED in a real OHCA crisis. It is also important to note that, although CPR and AED intentions were strongly correlated, there are subtle differences in relevant concerns and barriers that need to be addressed[ 17 ]. Nevertheless, robustly designed experimental studies are warranted to examine the effects of the TPB-based teaching compared with the traditional approach. Limitations and future directions There were several limitations in this study. First, training details such as organisation, course types, and duration, as well as the number of previous trainings, were not requested for further analysis. Second, snowball sampling may lead to a biased sample and limited representativeness of the trained laypersons in Hong Kong. It was noted that around one-third of the respondents were students, and around 40% aged 25 years or below. However, this age distribution was comparable to a local study targeting first-aid learners [ 33 ], reassuring a certain degree of representativeness in our sample. Lastly, psychomotor skills were not measured and thus were not included in the model, which is an essential part of layperson BLS training. Future research should investigate the interplay of skills, knowledge, and PBC to gain a comprehensive understanding of laypeople’s intentions regarding CPR and AED. Robustly designed studies conducted in HK with mixed methods, such as qualitative interviews, discrete choice experiments, and surveys, are warranted to delve into the factors and preferences of lay-rescuers, thus enabling and facilitating the development of ‘Intention-focused’ pedagogy for layperson CPR and AED training. Conclusions In summary, this local study provided empirical data for CPR and AED refresher courses based on the TPB framework. The mediation effects of attitude, subjective norms, and PBC on the association between time since the last training and BLS intention were unveiled. Knowledge was not associated with intention despite the fact that it diminished with time, corroborating the ‘know-do’ gap in layperson resuscitation. Extensive research on the decision-making process in bystander CPR and AED is warranted to excel the layperson rescuer training by incorporating the ‘Intention-focused’ approach and addressing community-specific concerns. Abbreviations AHA American Heart Association BLS basic life support ERC European Resuscitation Council HK Hong Kong OHCA out-of-hospital cardiac arrests PBC perceived behavioural control TPB Theory of Planned Behaviour Declarations Ethics approval and consent to participate Ethics approval was obtained from the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (reference no: 158-21). Completion of the survey implied consent to participate. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contributions VCWT and AWLK conceived and designed the study. AWLK supervised the conduct of the entire project. VCWT conducted the data collection, data analysis, and interpretation. NCYY provided statistical advice on data analysis. VCWT drafted the manuscript, and all authors contributed substantially to its revision. Acknowledgements We sincerely thank Prof Phoenix Mo for her expert advice on conceptual and statistical analysis and Miss Lisa Chan for supporting the graphic illustration in the online questionnaires. References Brooks, S. C. et al. Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation. Circulation 145 (13). (2022). Xu, R. H., Sun, R. & Fu, S-N. Out-of-Hospital Cardiac Arrest Before and During the COVID-19 Pandemic in Hong Kong: Registry-Based Study From 2017 to 2023. JMIR Public. Health Surveill . 10 , e56054 (2024). Dainty, K. N. et al. 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Circulation 146 (25), e483–e557 (2022). Greif, R. et al. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 156 , A188–A239 (2020). Farquharson, B. et al. The psychological and behavioural factors associated with laypeople initiating CPR for out-of-hospital cardiac arrest: a systematic review. BMC Cardiovasc. Disord. 23 (1), 19 (2023). Greif, R. et al. 2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 150 (24), e580–e687 (2024). Chen, C. et al. Global Sex Disparities in Bystander Cardiopulmonary Resuscitation After Out-of‐Hospital Cardiac Arrest: A Scoping Review. J. Am. Heart Association . 13 (18), e035794 (2024). Fan, M., Leung, L-P., Leung, R., Hon, S. & Fan, K. L. Readiness of Hong Kong secondary school teachers for teaching cardiopulmonary resuscitation in schools: A questionnaire survey. Hong Kong J. Emerg. Med. 26 (3), 174–178 (2019). Hung, K. K., Leung, C., Siu, A. & Graham, C. A. Good Samaritan law and bystander cardiopulmonary resuscitation: cross-sectional study of 1223 first-aid learners in Hong Kong. Hong Kong J. Emerg. Med. 28 (1), 22–29 (2021). Volunteer rescuers and Good Samaritan Law in Hong Kong. [ https://cmel.hku.hk/legal_update/volunteer-rescuers-and-good-samaritan-law-in-hong-kong/] Yang, J., Wang, M., Xu, S. & Bian, Y. Study on the application effect of problem-based learning with situational simulation teaching method in cardiopulmonary resuscitation training. Signa Vitae 20 (9). (2024). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 16 Apr, 2026 Reviews received at journal 22 Aug, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers invited by journal 29 Jul, 2025 Editor assigned by journal 29 Jul, 2025 Editor invited by journal 14 Jul, 2025 Submission checks completed at journal 11 Jul, 2025 First submitted to journal 11 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7093960","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":493443046,"identity":"fa006200-72dc-4b5a-8482-e40dca869da9","order_by":0,"name":"Victor C. W. TAM","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYDACZmTOBwaGBAkgDcQHDPBoYWwAM9gYGBhnEKWFAUkLMw8xWgyOMz9/8HGPXWKDfPPTzTY1h/MkG5gP3uZhuGOMU8thNsPGGc+SExvY2Mxu5xw7XCzNwJZszcPwzAyXFslmHsZmngMHchvYGMxu5zYcTpzHwGMmzcNw2IYILezfbluCtfB/w6uFnxmuhcfsNiNQy2wGHjaQFpwO42dmM5w540ByfRtbTtnNnmPpiTOb2Ywt5xgcxul9Nv7DDz58OGBnzM98fNuNHzXWiTOONz+88abisGEDLj1wvXAWOD3gi8hRMApGwSgYBQQBAJyOU275IAHKAAAAAElFTkSuQmCC","orcid":"","institution":"Chinese University of Hong Kong","correspondingAuthor":true,"prefix":"","firstName":"Victor","middleName":"C. W.","lastName":"TAM","suffix":""},{"id":493443047,"identity":"a07edb83-3b86-446e-b02a-770ba0a02a4e","order_by":1,"name":"Nelson C. Y. YEUNG","email":"","orcid":"","institution":"Chinese University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Nelson","middleName":"C. Y.","lastName":"YEUNG","suffix":""},{"id":493443049,"identity":"894dacfb-406a-4c7d-808a-32e7d372d5b5","order_by":2,"name":"Anthony Wai Leung KWOK","email":"","orcid":"","institution":"Tung Wah College","correspondingAuthor":false,"prefix":"","firstName":"Anthony","middleName":"Wai Leung","lastName":"KWOK","suffix":""}],"badges":[],"createdAt":"2025-07-10 14:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7093960/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7093960/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88135570,"identity":"07b908ba-5fe2-4fd6-9285-5dca9dce457d","added_by":"auto","created_at":"2025-08-01 21:38:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":173809,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProposed mediation model\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.Proposedmediationmodel.png","url":"https://assets-eu.researchsquare.com/files/rs-7093960/v1/ecfc7c102427d7e0fca5bdb4.png"},{"id":88135571,"identity":"f9962922-d46b-4d8e-8801-2524cd475ebe","added_by":"auto","created_at":"2025-08-01 21:38:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":319845,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHeatmap of intention to deliver BLS (N = 678). \u003cbr\u003e\n \u003c/strong\u003eA strong correlation was found between CPR and AED intention (ρ = .71, \u003cem\u003eP \u003c/em\u003e\u0026lt; .001)\u003c/p\u003e","description":"","filename":"Figure2.Heatmapintention.png","url":"https://assets-eu.researchsquare.com/files/rs-7093960/v1/bfafb904b32c52bac10d1072.png"},{"id":88136080,"identity":"9f512c7a-019c-4781-9c2c-8cc4ecd6aa89","added_by":"auto","created_at":"2025-08-01 21:54:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":204111,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMediation model of BLS intention and years since the last training via TPB determinants (N = 678).\u003cbr\u003e\n\u003c/strong\u003eUnstandardised regression coefficients were presented. All structural path coefficients in the solid line were statistically significant at ***\u003csup\u003e \u003c/sup\u003e\u003cem\u003eP \u003c/em\u003e\u0026lt; .001. Dashed paths represent non-significant coefficients. c represents the total effect from the years since the last training to BLS intention; c’ represents the direct effect from years since the last training to BLS intention after considering the indirect effects by the mediators. Covariates (gender, age, monthly income, whether trained in both CPR and AED) were not shown for simple illustration.\u003c/p\u003e","description":"","filename":"Figure3.MediationmodelBLSintention.png","url":"https://assets-eu.researchsquare.com/files/rs-7093960/v1/81e69c80cd085c9c89f13e1e.png"},{"id":88136162,"identity":"c9a2a7b1-5089-48d3-bf82-e104a644d025","added_by":"auto","created_at":"2025-08-01 22:02:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1360664,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7093960/v1/573a7f9a-6b6a-43b5-872c-510ec90853ef.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Keep The Safety Net Intact Through Refresher: Resuscitation Intention In Chinese Lay- Rescuers Decreases With Time Via Mediation Of Theory Of Planned Behaviours Determinants But Not Knowledge—A Cross-Sectional Survey","fulltext":[{"header":"Background","content":"\u003cp\u003eThere are around 3.8\u0026nbsp;million people who experience out-of-hospital cardiac arrests (OHCA) each year around the globe, and only one in ten survives[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Hong Kong (HK), the survival rate upon hospital arrival was alarmingly low, at 8.3%, with only 44.6% of victims receiving bystander cardiopulmonary resuscitation (CPR), and 1.9% undergoing bystander defibrillation by an automated external defibrillator (AED)[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While OHCA can occur anywhere in the community where healthcare professionals might not be around as first responders, CPR and AED training for community members are essential to facilitate timely bystander resuscitation to OHCA victims. This serves as a safety net in the community, enhancing the survival of OHCA victims[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Given that resuscitation skills and willingness could decay over time[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], certified lay rescuers are required to attend the refresher course and renew their certificates every two to three years in HK, Europe, and the United States[\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEarly bystander Basic Life Support (BLS), comprising CPR and AED, was significantly associated with the survival of OHCA patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Public CPR and AED courses, along with refresher sessions, are crucial for equipping and retaining community members with essential knowledge and skills. In addition, accumulating evidence has revealed the importance of addressing intention, or willingness, to perform CPR and AED as the key to successful bystander resuscitation. The European Resuscitation Council (ERC) initiated a new session discussing \u0026lsquo;the public willingness to perform CPR\u0026rsquo; in its upcoming 2025 guidelines, addressing research gaps from the learner\u0026rsquo;s perspective in resuscitation educational research[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Besides, the American Heart Association (AHA) advocated the \u0026lsquo;Intention-focused model for bystanders\u0026rsquo; to boost the bystander CPR rate[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], positing \u0026lsquo;Intention\u0026rsquo; at the core of the lay-rescuer training strategy.\u003c/p\u003e\u003cp\u003eThe \u0026lsquo;Intention-focused\u0026rsquo; model incorporated the Theory of Planned Behaviour (TPB), featuring three determinants: attitude, subjective norms, and perceived behavioural control (PBC)[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition to knowledge and skills, previous studies have shown that attitude and subjective norms are the strongest predictors of CPR intention, with the suggested model accounting for 51\u0026ndash;57% of the variation in intention [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Besides, it has been highlighted that considering socio-demographics, training factors, and barriers associated with community willingness is crucial in layperson resuscitation training[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In HK, our team demonstrated that CPR and AED willingness were not associated with knowledge level but all TPB determinants[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the current shift in focus to boost bystanders\u0026rsquo; intention to initiate CPR [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], local refresher courses remained focused on revisiting knowledge and skills by repeated practice. Furthermore, it is unclear how the depletion of willingness since the last training was influenced by the cognitive and psychobehavioural variables. By understanding the potential mediating role of the TPB determinants on the decay of resuscitation intention over time, training institutes could optimise the refresher courses to boost lay-rescuers\u0026rsquo; intention.\u003c/p\u003e\u003cp\u003eThis article aims to investigate the potential mediating effects of knowledge and TPB determinants on the relationship between the length of time since the last training and BLS intention among trained lay-rescuers. We hypothesised that (i) the years since the lasting training was negatively associated with attitude, subjective norms, PBC and knowledge; (ii) attitude, subjective norms, PBC and knowledge were positively associated with BLS intention; and (iii) years since the lasting training was negatively associated with BLS intention, mediated by attitude, subjective norms, PBC and knowledge. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the proposed mediation model.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy design and population\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis paper presents the secondary analysis of an online cross-sectional survey conducted in HK from December 28, 2021, to April 14, 2022, using snowball sampling on social media, including WhatsApp, Instagram, and Facebook. Ethics approval was obtained from the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (reference no: 158\u0026thinsp;\u0026minus;\u0026thinsp;21). The study was conducted in accordance with the Declaration of Helsinki. Inclusion criteria were (i) living in HK, (ii) understanding Chinese, (iii) aged 18\u0026ndash;64 years, (iv) having been trained for a CPR/AED course, and (v) implied consent by survey completion. Excluding healthcare professionals, responses from 678 trained lay adults were extracted from 1449 valid responses for this analysis. This sample met the minimum sample size of 393 required for parallel mediation analysis[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eData collection and measurements\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDemographics, such as age and gender, were collected anonymously. Participants were asked whether they had ever received CPR or AED training. The number of years since the last training (\u0026lt;\u0026thinsp;1 year, 1\u0026ndash;3 years, 3\u0026ndash;5 years, and \u0026gt;\u0026thinsp;5 years ago) was asked for those who have been trained.\u003c/p\u003e\u003cp\u003eThe Intention to Deliver BLS scale was used, which includes four sub-scales: (i)overall BLS intention, (ii)attitude, (iii)subjective norms, and (iv)perceived behavioural control measured in 15 items[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This TPB-based instrument was established and validated in 1449 community members in HK. Participants were asked to rate their intention, in case of an OHCA, to perform CPR and AED on two separate 5-point (0\u0026ndash;4 points) Likert scale (Sample item: \u003cem\u003e\u0026ldquo;I will perform CPR without hesitation on an unresponsive victim with no normal breathing in the community\u0026rdquo;\u003c/em\u003e). The mean score of these two items was calculated to represent the overall BLS intention, which served as the dependent variable in this study [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eProposed mediators, including attitude, subjective norms, and PBC, were assessed using 5-point (0\u0026ndash;4 points) Likert scales. The mean scores of items were calculated to represent the corresponding sub-scales. Attitude was represented by four items with good reliability (α\u0026thinsp;=\u0026thinsp;0.77)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Sample item:\u003cem\u003e\u0026ldquo;CPR and AED are beneficial to an unresponsive victim\u0026rdquo;\u003c/em\u003e. Subjective norms were represented by five items with excellent reliability (α\u0026thinsp;=\u0026thinsp;0.93)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Sample item: \u003cem\u003e\u0026ldquo;I believe that the general public expects me to perform CPR and use AED on an unresponsive victim\u0026rdquo;\u003c/em\u003e. Perceived behavioural control was represented by four items with an excellent reliability (α\u0026thinsp;=\u0026thinsp;0.95)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Sample item: \u003cem\u003e\u0026ldquo;I am confident to perform CPR and use AED\u0026rdquo;\u003c/em\u003e. Knowledge, also proposed as a mediator, was represented by the number of correct answers out of eight multiple-choice questions regarding CPR and AED.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eData were analysed using IBM SPSS Statistics version 26 (SPSS Inc., Chicago, USA). Correlation between the intention to deliver CPR and AED was examined by Spearman\u0026rsquo;s rank correlation (ρ). Analysis of variance (ANOVA) with post-hoc Tukey\u0026rsquo;s range tests was used to compare the mean scores of variables across years since the last training. Correlations between the time since last training, the proposed mediators, and the BLS intention mean scores were examined by Pearson\u0026rsquo;s correlation (\u003cem\u003er\u003c/em\u003e). A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003ePROCESS Macro was used to examine the mediating effects of knowledge, attitude, subjective norms, and PBC on the relationship between the years since last training and BLS intention. The mediation analysis was supplemented with 5000 bootstrap replications. A statistically significant effect was considered if the 95% bias-corrected CI did not include zero.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eDemographics and training background\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe majority of the respondents were female (52.1%), aged between 18 and 25 years (39.1%), attained a diploma or a bachelor\u0026rsquo;s degree as the highest educational level (64.2%), and earned less than HKD15001 (37.6%). For occupation, approximately one-third (33.3%) were students, another one-third (35.0%) were civilians, and the remaining one-third had various occupations. Regarding resuscitation training experience, over half of them received both CPR and AED training (64.0%). Most of the respondents received their last training in the past year (42.6%), while 17.6% of them trained more than 5 years ago. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the characteristics of respondents.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant characteristics (N\u0026thinsp;=\u0026thinsp;678)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eDemographic characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFrequency (Percentage [%])\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e353 (52.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e325 (47.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e18\u0026ndash;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e265 (39.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e26\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e222 (32.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e41\u0026ndash;64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e191 (28.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eEducational level\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSecondary or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e110 (16.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePost-secondary (includes diploma and undergraduate)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e435 (64.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePostgraduate (includes Master and above)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e133 (19.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eMonthly income\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026lt;\u003cspan\u003e$\u003c/span\u003e15,001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e255 (37.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e15,001-\u003cspan\u003e$\u003c/span\u003e30,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e181 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e30,001-\u003cspan\u003e$\u003c/span\u003e45,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e120 (17.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e45,001-\u003cspan\u003e$\u003c/span\u003e60,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48 (7.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026gt;\u003cspan\u003e$\u003c/span\u003e60,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74 (10.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTraining backgrounds\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFrequency (Percentage [%])\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTraining type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEither CPR or AED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e244 (36.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCPR \u0026amp; AED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e434 (64.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eYears since the last training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWithin 1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e289 (42.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026ndash;2 years ago\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e141 (20.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u0026ndash;5 years ago\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e129 (19.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMore than 5 years ago\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e119 (17.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eIntention to deliver CPR and AED\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOver half of the respondents were willing to perform CPR (51.8%) and AED (54.7%), while more than one-fifth disagreed to perform CPR (21.2%) or AED (23.1%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A strong correlation was revealed between CPR and AED intention (ρ\u0026thinsp;=\u0026thinsp;0.71; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eCorrelation between major variables\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the descriptive statistics and correlation among variables. Years since the last training were negatively correlated with intention (\u003cem\u003er\u003c/em\u003e=-0.33; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), knowledge (\u003cem\u003er\u003c/em\u003e=-0.52; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), attitude (\u003cem\u003er\u003c/em\u003e=-0.30; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), subjective norms (\u003cem\u003er\u003c/em\u003e=-0.33; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001) and PBC (\u003cem\u003er\u003c/em\u003e=-0.45; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001). Knowledge and all TPB determinants were positively correlated with BLS intention (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.34\u0026ndash;0.67; all \u003cem\u003ePs\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive statistics and correlates of BLS intention and predictors among trained lay-rescuers (N\u0026thinsp;=\u0026thinsp;678)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Time since the last training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. BLS intention\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.33***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Knowledge\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.52***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.34***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Attitude\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.30***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.48***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.33***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Subjective norms\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.33***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.57***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.31***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.50***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Perceived behavioural control\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.45***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.67***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.44***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.45***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.63***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMean\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCronbach\u0026rsquo;s alpha\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.94\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eFootnote:\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e Highest score\u0026thinsp;=\u0026thinsp;4\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003e\u0026Dagger;\u003c/sup\u003e Highest score\u0026thinsp;=\u0026thinsp;8\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003e***\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eBLS\u003c/em\u003e, Basic Life Support.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor demographics, education level was not significantly correlated with BLS intention (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003; \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.93). Being male (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.22; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), older age (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.12; \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.002), higher monthly income (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.09; \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.02), and trained in both CPR and AED (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.37; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001) were significantly correlated with BLS intention, thus being included as covariates.\u003c/p\u003e\u003cp\u003e\u003cem\u003eMediation analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePredictors in the hypothesised model explained 51.9% of the variance in BLS intention (\u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.519; \u003cem\u003eF\u003c/em\u003e\u003csub\u003e9, 668\u003c/sub\u003e=80.15; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Three TPB determinants mediated the relationship between the years since the last training and BLS intention. Years since the last training were negatively associated with attitude (B=-0.10; se\u0026thinsp;=\u0026thinsp;.02; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), subjective norms (B=-0.18; se\u0026thinsp;=\u0026thinsp;.03; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), and PBC (B=-0.31; se\u0026thinsp;=\u0026thinsp;.03; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001). Higher attitude (B\u0026thinsp;=\u0026thinsp;0.36; se\u0026thinsp;=\u0026thinsp;.07; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), subjective norms (B\u0026thinsp;=\u0026thinsp;0.24; se\u0026thinsp;=\u0026thinsp;.05; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001), and PBC (B\u0026thinsp;=\u0026thinsp;0.45; se\u0026thinsp;=\u0026thinsp;.04; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001) scores were associated with higher BLS intention. Similarly, years in the last training were negatively associated with knowledge (B=-0.54; se\u0026thinsp;=\u0026thinsp;.05; \u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001); however, knowledge was not significantly associated with BLS intention (B\u0026thinsp;=\u0026thinsp;0.02; se\u0026thinsp;=\u0026thinsp;.02; \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.33).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe indirect effects from years since the last training to BLS intention via attitude (B=-0.04; se\u0026thinsp;=\u0026thinsp;0.01; 95%CI, -0.06 to -0.02), subjective norms (B=-0.04; se\u0026thinsp;=\u0026thinsp;0.01; 95%CI, -0.07 to -0.02), and PBC (B=-0.14; se\u0026thinsp;=\u0026thinsp;0.02; 95%CI, -0.18 to -0.10) were significant. However, the indirect effect of knowledge was not significant (B=-0.01; se\u0026thinsp;=\u0026thinsp;0.01; 95%CI, -0.03 to 0.02). The total indirect effect was significant (B=-0.23; se\u0026thinsp;=\u0026thinsp;0.03; 95%CI, -0.29 to -0.18) while the direct effect was not significant (B=-0.02; se\u0026thinsp;=\u0026thinsp;0.03; 95%CI, -0.08 to 0.50). Therefore, a full mediation was suggested.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study to investigate the mediating role of the three TPB determinants on the relationship between lay-rescuers' CPR and AED intentions and the timespan since the last training, aiming to provide insights into boosting lay-rescuers\u0026rsquo; resuscitation intentions during refresher training. The AHA has since advocated the \u0026lsquo;Intention-focused model for bystanders\u0026rsquo; to boost the bystander CPR rate by addressing their intention and the associated factors[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Our findings revealed that the intention to perform BLS decreased over time since the last training, and this relationship was mediated by all TPB determinants. It is worth noting that although knowledge level decreased with time, it was not significantly associated with BLS intention.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWeaving the safety net for OHCA victims\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHigh-quality bystander CPR and early defibrillation constitute the second and third rings in an adult chain of survival in an OHCA victim, which were significantly associated with the patient\u0026rsquo;s survival[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. As OHCA can occur anywhere at any time, when healthcare professionals are not always available, CPR and AED training for laypersons could establish a safety net within a community to save lives. It was demonstrated that lay rescuers could perform CPR efficiently, and there is no difference in one-month survival with favourable neurological outcomes for OHCA patients receiving CPR by laypersons and off-duty healthcare professionals[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. While previous studies have revealed the deterioration of skills and willingness to perform CPR[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], refresher courses play a crucial role in maintaining the readiness of bystanders to perform resuscitation and keeping this safety net intact.\u003c/p\u003e\u003cp\u003e\u003cem\u003eKnowledge revisit in refresher\u003c/em\u003e\u003c/p\u003e\u003cp\u003eLocal refresher courses currently focus on revisiting relevant knowledge and skills, rarely addressing lay-rescuers' intentions and psychobehavioural aspects [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Skills and knowledge are undoubtedly fundamental in CPR and AED training, but mastering them does not necessarily translate into intention and actions. This Know-Do gap was evident in a previous study, in which only 29% of respondents were willing to offer CPR, despite having recently completed the BLS course[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The current study revealed that, despite knowledge decreasing over time, it was not associated with BLS intention, reinforcing that \u0026lsquo;knowing it\u0026rsquo; does not necessarily mean being \u0026lsquo;willing to do it\u0026rsquo;. However, inconsistent findings were reported in studies from Malaysia and China[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A positive association was apparently more prevalent among university students than older adults. It may be because the younger population tends to consider \u0026lsquo;correctness\u0026rsquo; from a theoretical perspective during their student years, while older people are inclined to be driven by life experience and a sense of social responsibility [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Nonetheless, this finding urged a deep reflection on the proportion of revisiting knowledge in the refresher course, especially among older adults.\u003c/p\u003e\u003cp\u003e\u003cem\u003eTPB determinants as mediators\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile all three TPB determinants were significant mediators, PBC was the strongest predictor of resuscitation intention and the strongest mediation path compared to attitude and subjective norms. Perceived behavioural control was defined as the degree to which ones feel that s/he can control the performance of the behaviour [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It has often been confused with self-efficacy, which refers to the perceived capabilities in performing the specific behaviours [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. While PBC could be correlated with self-efficacy, it is also a measure of how much one feels that external constraints possibly limit their control over action.\u003c/p\u003e\u003cp\u003eOur findings were different from previous studies using TPB to predict resuscitation intention among college students in USA [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], university students [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and civil servants [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] in mainland China, where attitude and subjective norms were the strongest predictors of CPR intention. There are two major differences between the current study and the existing research which might explain the discrepancies. Firstly, there were fundamental differences in modelling, which the current study investigated the relationship between intention and timespan since the last training, with three TPB determinants as mediators instead of independent variables. Perceived behavioural control appeared to have a stronger negative correlation with the timespan since the last training when compared to the other two determinants; therefore, it had a stronger mediating effect.\u003c/p\u003e\u003cp\u003eAnother plausible reason could be the distinct population of trained lay-rescuers in our study. While untrained persons might consider initiating resuscitation more by their intuitions or perceived civil responsibility, trained layman with prior skill training might be more aware that this is their decision to initiate resuscitation, and they might have propensity to considerate whether they can perform the skills well and the possible consequences if they choose to initiate resuscitation.\u003c/p\u003e\u003cp\u003e\u003cem\u003eDeveloping culturally-adapted \u0026lsquo;Intention-Focused\u0026rsquo; pedagogy\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile the \u0026lsquo;Intention-Focused\u0026rsquo; paradigm for bystander CPR training was first introduced in 2015[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], it has been limitedly adopted in HK. The model incorporated the TPB as the theoretical backbone, focusing on intention as the immediate determinant of performing CPR, with attitude, subjective norms, and PBC as the determinants of intention[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Bystander characteristics were considered \u0026lsquo;distal\u0026rsquo; factors, together with the interplay of skills, environmental constraints, and intention to perform CPR. Previous studies have identified various common barriers and facilitators to bystander resuscitation, for example, overwhelming fear and distress, uncertainty about when CPR is appropriate, and inability to position the patient on a flat firm surface [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Some barriers may be regionally or culturally specific. For instance, Black or Hispanic victims were less likely to receive CPR in the US [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. While female gender patients were, in general, less likely to receive bystander resuscitation, this barrier was expected to be more prominent in conservative cultural, social and religious norms of certain regions in Asia and Africa [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These barriers should be addressed and translated into a willingness to perform resuscitation through the TPB determinants during public training.\u003c/p\u003e\u003cp\u003eAlthough AHA has advocated the \u0026lsquo;Intention-focused model for bystanders\u0026rsquo; later in 2022[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], there were no comprehensive practical guidelines on how to integrate this concept into refresher training. It is reasonable not to have a one-size-fits-all training package as the resuscitation intentions of a community could vary significantly across regions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Yet, enormous efforts are warranted to investigate the factors associated with laypersons\u0026rsquo; CPR and AED intention and understand the local context in order to tailor effective, culturally adaptive training and refresher courses. For instance, fear of legal liability was rated as the top barrier in Hong Kong[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. However, Good Samaritan Law is not in force, despite the majority (95.2%) of first-aid learners supporting its enactment [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Hong Kong follows the English common law, in which holding a layperson rescuer liable for negligence in a resuscitation attempt is generally cautious[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Discussing legal liability in a refresher course could acknowledge learners\u0026rsquo; legal concerns, provide a better understanding of the legal context in HK, and thus facilitate them in making an informed choice of action.\u003c/p\u003e\u003cp\u003eRegarding the format of the refresher, it was found that a problem-based approach, combined with simulation and debriefing, significantly outperformed traditional training in improving CPR performance[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Simulation realism could stimulate participants\u0026rsquo; innate sense of social responsibility. Timely debriefing facilitates reflection on one\u0026rsquo;s preferences and considerations in a simulated OHCA crisis, fostering the exchange of ideas among peers and addressing collective concerns. The paradigm shift in current pedagogy demands not just the establishment of a lesson plan, but also the trainer's belief and competence in addressing psychobehavioural concerns and boosting laypeople\u0026rsquo;s intention to deliver CPR and AED in a real OHCA crisis. It is also important to note that, although CPR and AED intentions were strongly correlated, there are subtle differences in relevant concerns and barriers that need to be addressed[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Nevertheless, robustly designed experimental studies are warranted to examine the effects of the TPB-based teaching compared with the traditional approach.\u003c/p\u003e\u003cp\u003e\u003cem\u003eLimitations and future directions\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThere were several limitations in this study. First, training details such as organisation, course types, and duration, as well as the number of previous trainings, were not requested for further analysis. Second, snowball sampling may lead to a biased sample and limited representativeness of the trained laypersons in Hong Kong. It was noted that around one-third of the respondents were students, and around 40% aged 25 years or below. However, this age distribution was comparable to a local study targeting first-aid learners [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], reassuring a certain degree of representativeness in our sample. Lastly, psychomotor skills were not measured and thus were not included in the model, which is an essential part of layperson BLS training.\u003c/p\u003e\u003cp\u003eFuture research should investigate the interplay of skills, knowledge, and PBC to gain a comprehensive understanding of laypeople\u0026rsquo;s intentions regarding CPR and AED. Robustly designed studies conducted in HK with mixed methods, such as qualitative interviews, discrete choice experiments, and surveys, are warranted to delve into the factors and preferences of lay-rescuers, thus enabling and facilitating the development of \u0026lsquo;Intention-focused\u0026rsquo; pedagogy for layperson CPR and AED training.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, this local study provided empirical data for CPR and AED refresher courses based on the TPB framework. The mediation effects of attitude, subjective norms, and PBC on the association between time since the last training and BLS intention were unveiled. Knowledge was not associated with intention despite the fact that it diminished with time, corroborating the \u0026lsquo;know-do\u0026rsquo; gap in layperson resuscitation. Extensive research on the decision-making process in bystander CPR and AED is warranted to excel the layperson rescuer training by incorporating the \u0026lsquo;Intention-focused\u0026rsquo; approach and addressing community-specific concerns.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAHA American Heart Association\u003c/p\u003e\u003cp\u003eBLS basic life support\u003c/p\u003e\u003cp\u003eERC European Resuscitation Council\u003c/p\u003e\u003cp\u003eHK Hong Kong\u003c/p\u003e\u003cp\u003eOHCA out-of-hospital cardiac arrests\u003c/p\u003e\u003cp\u003ePBC perceived behavioural control\u003c/p\u003e\u003cp\u003eTPB Theory of Planned Behaviour\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the Survey and Behavioural Research Ethics Committee of The Chinese University of Hong Kong (reference no: 158-21). Completion of the survey implied consent to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVCWT and AWLK conceived and designed the study. AWLK supervised the conduct of the entire project. VCWT conducted the data collection, data analysis, and interpretation. NCYY provided statistical advice on data analysis. VCWT drafted the manuscript, and all authors contributed substantially to its revision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank Prof Phoenix Mo for her expert advice on conceptual and statistical analysis and Miss Lisa Chan for supporting the graphic illustration in the online questionnaires.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBrooks, S. C. et al. Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation. \u003cem\u003eCirculation\u003c/em\u003e \u003cb\u003e145\u003c/b\u003e(13). 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[\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cmel.hku.hk/legal_update/volunteer-rescuers-and-good-samaritan-law-in-hong-kong/]\u003c/span\u003e\u003cspan address=\"https://cmel.hku.hk/legal_update/volunteer-rescuers-and-good-samaritan-law-in-hong-kong/]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang, J., Wang, M., Xu, S. \u0026amp; Bian, Y. Study on the application effect of problem-based learning with situational simulation teaching method in cardiopulmonary resuscitation training. \u003cem\u003eSigna Vitae\u003c/em\u003e \u003cb\u003e20\u003c/b\u003e(9). (2024).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"willingness, intention, cardiopulmonary resuscitation, automated external defibrillation, lay rescuers, Theory of Planned Behaviour, attitude, subjective norms, perceived behavioural control, knowledge","lastPublishedDoi":"10.21203/rs.3.rs-7093960/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7093960/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Out-of-hospital cardiac arrest (OHCA) threatens thousands of lives each year inHong Kong (HK). While early cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED) are essential to improve OHCA survival, local bystander resuscitation attempt rates were low. To encourage bystander resuscitation and establish a safety net in the community to save lives, the ‘Intention-focused’ training approach based on the Theory of Planned Behaviour (TPB) is advocated, aiming to boost lay-rescuers' willingness to perform Basic Life Support (BLS) by addressing attitude, subjective norms, and perceived behavioural control (PBC). However, refresher courses in Hong Kong still focus on revisiting resuscitation knowledge and skills. This article aimed to investigate the association between time since last training and BLS intention, and the potential mediating role of knowledge and Theory of Planned Behaviour (TPB) determinants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A cross-sectional online survey of 678 non-healthcare adult lay-rescuerswas conducted in 2022 using snowball sampling. Participants were categorised by years since last training: trained within 1 year (n=289), 1-2 years (n=141), 3-5 years (n=129), and \u0026gt;5 years (n=119). The Intention to Deliver BLS scale was used. Mediation analysis was conducted using SPSS PROCESS Macro.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eYears since the last training were negatively associated with attitude (B=-0.10; \u003cem\u003eP\u0026lt;\u003c/em\u003e.001), subjective norms (B=-0.18; \u003cem\u003eP\u0026lt;\u003c/em\u003e.001), and PBC (B=-0.31; \u003cem\u003eP\u0026lt;\u003c/em\u003e.001). Higher attitude (B=0.36; \u003cem\u003eP\u0026lt;\u003c/em\u003e.001), subjective norms (B=0.24; \u003cem\u003eP\u0026lt;\u003c/em\u003e.001), and PBC (B=0.45; \u003cem\u003eP\u0026lt;\u003c/em\u003e.001) scores were associated with higher BLS intention. Knowledge was negatively associated with time since last training (B=-0.54; \u003cem\u003eP\u0026lt;\u003c/em\u003e.001), but not significantly associated with BLS intention (B=0.02; \u003cem\u003eP=\u003c/em\u003e.33).\u003c/p\u003e\n\u003cp\u003eMediation analysis revealed significant indirect effects of years since last training on BLS intention via attitude (B=-0.04; 95%CI, -0.06 to -0.02), subjective norms (B=-0.04; 95%CI, -0.07 to -0.02), and PBC (B=-0.14; 95%CI, -0.18 to -0.10), but insignificant for knowledge (B=-0.01, 95%CI; -0.03 to 0.02). The direct effect was insignificant (B=-0.02; 95%CI, -0.08 to 0.50), suggesting a full mediation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Resuscitation intention decreases with time through TPB determinants, but not knowledge. Comprehensive reviews of the current refresher strategy, focusing on knowledge and skill revisit, are warranted. Future research should focus on developing culturally-adapted 'Intention-focused' refresher pedagogies that address these psychobehavioural factors.\u003c/p\u003e","manuscriptTitle":"Keep The Safety Net Intact Through Refresher: Resuscitation Intention In Chinese Lay- Rescuers Decreases With Time Via Mediation Of Theory Of Planned Behaviours Determinants But Not Knowledge—A Cross-Sectional Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 21:38:30","doi":"10.21203/rs.3.rs-7093960/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"114107117615772492555924449238322622876","date":"2026-04-16T17:28:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-22T08:14:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158029929377654493788033690935945097544","date":"2025-07-31T01:13:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-29T09:38:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-29T09:37:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-14T09:11:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-11T07:15:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-07-11T07:12:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a32fbc5b-634e-4330-b54c-8d6d5d5ef570","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":52401346,"name":"Health sciences/Cardiology"},{"id":52401347,"name":"Health sciences/Health care"},{"id":52401348,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-08-01T21:38:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-01 21:38:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7093960","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7093960","identity":"rs-7093960","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}