Introduction
In the United States, more than 356,000 people suffer an out-of-hospital cardiac arrest (OHCA) each year.Reference Benjamin, Virani and Callaway1 Though prompt initiation of bystander cardiopulmonary resuscitation (BCPR) has been linked to significantly reduced mortality in OHCA, rates of BCPR remain low.Reference Benjamin, Virani and Callaway1-Reference Blom, Oving, Berdowski, van Valkengoed, Bardai and Tan10 While several studies have examined factors that impact the likelihood of receiving BCPR, the role of gender has been under-examined, and the definition of “bystander” remains unclear in prehospital literature. This study sought to examine gender disparities in OHCA BCPR and to evaluate whether the type of bystander influenced the likelihood of receiving intervention.
Despite advancements in prehospital medicine, nearly 90% of OHCA events will be fatal, equating to nearly 1,000 daily OHCA deaths.Reference Benjamin, Virani and Callaway1 Several factors have been linked to increased survival in OHCA, the most consistently demonstrated being early detection and intervention, not limited to medical personnel. Despite this, data from the Cardiac Arrest Registry to Enhance Survival (CARES; Emory University; Atlanta, Georgia USA) in 2020 placed the rate of BCPR at approximately 40.8%.Reference Benjamin, Virani and Callaway1 The investigation of various factors impacting BCPR rates remains an on-going area of research, for identifying potential areas of intervention could increase rates of BCPR, and consequently, patient survival. Though several studies have demonstrated gender as a factor in BCPR rates for OHCA, gender disparities in BCPR remain under-examined overall.Reference Blewer, McGovern and Schmicker2-Reference Blom, Oving, Berdowski, van Valkengoed, Bardai and Tan10 Some studies have found women suffering OHCA less likely to receive BCPR than men, though others have not identified gender-based differences in BCPR rates.Reference Blewer, McGovern and Schmicker2,Reference Ahn, Shin and Hwang6,Reference Liu, Ning and Eng Hock Ong8-Reference Blom, Oving, Berdowski, van Valkengoed, Bardai and Tan10 Several studies have found that men are significantly more likely to receive BCPR in arrests occurring in public settings, while women are more likely to receive BCPR at home.Reference Blewer, McGovern and Schmicker2,Reference Liu, Ning and Eng Hock Ong8 These findings prompt consideration of whether delineations in bystander type could impact existing gender disparities in BCPR.
A bystander has historically been defined as a person not being part of an organized medical response, though BCPR is also commonly equated to CPR being performed by any individual prior to Emergency Medical Services (EMS) arrival.Reference Jacobs, Nadkarni and Bahr11-Reference Maurer, Masterson and Tjelmeland13 While several types of BCPR exist, the term “bystander” itself does not delineate between individuals with no medical/CPR training and CPR-trained individuals or off-duty medical personnel, nor does it address the relationship of the individual to the patient. No prior study has differentiated between bystanders “known” to the patient (ie, friends or family members) and random individuals unknown to the patient (ie, “true” bystanders).
This study aimed to investigate the impact of gender on the likelihood of receiving BCPR during OHCA, with a specific focus on whether the bystander’s relationship to the patient may contribute to observed disparities. The primary outcome of the study was to examine differences in BCPR rates among men and women who experienced OHCA. The secondary outcome was to investigate whether bystanders were more likely to provide CPR based on their relationship to the victim, comparing “true” layperson CPR to CPR administered by family members or friends, and how these rates differed between men and women. For both outcomes, the null hypothesis of no difference between males and females was tested against the two-sided alternative hypothesis of significant difference.
Methods
This study was reviewed and approved by the Institutional Review Board at Cooper University (Camden, New Jersey USA; Protocol #23-062). A retrospective prehospital chart review was conducted for all encounters from a single urban EMS agency with a cardiac arrest occurring prior to EMS arrival from January 1, 2017 through June 30, 2022 (n = 701). For each encounter, the presence or lack of BCPR intervention was recorded, along with the relation of the bystander to the patient. Contrary to traditional terminology, which defines a bystander as any person present or nearby at the time of arrest, this study intentionally distinguished between bystanders known to the patient and those who were strangers. “True” BCPR was defined as CPR performed by a layperson unknown to the patient, excluding any friends or family members. All patients who experienced a cardiac arrest prior to EMS arrival and were 18 years or older were eligible for the study. Patients were excluded (n = 174) if they exhibited signs of obvious death, were physically inaccessible to bystanders, had CPR initiated by trained facility staff or police, had a do not resuscitate (DNR) order present on EMS arrival, had CPR initiated but were not in cardiac arrest, or were younger than 18 years old (Table 1). Chi square tests were used to evaluate the primary and secondary outcomes, with statistical significance defined as P < .05. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp.; Armonk, New York USA). All confidence intervals (CI) for exploratory outcomes are unadjusted for multiplicity and intended for hypothesis generation only; they should not be used to infer statistical significance.
Table 1. Excluded Encounters in Study (N = 174)
Abbreviations: CPR, cardiopulmonary resuscitation; DNR, do not resuscitate.
Results
With regards to the primary outcome, 701 cardiac arrest encounters were examined: 250 female (35.7%) and 451 male (64.3%). Overall, men were more likely to receive BCPR than women; 123 (27.3%) men received BCPR compared to 48 (19.2%) women (OR = 1.58; 95%CI, 1.08-2.30; P = .02).
With regards to the secondary outcome, 42 men (34.1%) received CPR from a “true” bystander while 81 men (65.9%) received CPR from a family member or friend; by stark comparison, only eight women total (16.7%) received BCPR from a “true” bystander while 40 (83.3%) received CPR from a friend or family member (Figure 1). Among those who received BCPR, women were significantly more likely than men to have received it from a family member or friend (83.3% versus 65.9%; OR = 2.59; 95%CI, 1.11-6.04; P = .03) while men were more likely to receive “true” layperson BCPR. Table 2 provides a summary of data across 2017-2022, while Figure 2 provides a visual representation of the data stratified by year. Please note, the asterixis in both Table 2 and Figure 2 indicate the 2022 data were pooled for one-half of the year, spanning January 1 through June 30.
Figure 1. Comparison of Bystander CPR Type Received by Men and Women (2017-2022).
Abbreviation: CPR, cardiopulmonary resuscitation.
Table 2. Overall Data Summary
Note: * 2022 data were pooled for one-half of the year, spanning January 1 through June 30.
Abbreviation: CPR, cardiopulmonary resuscitation.
Figure 2. Comparison of Gender Differences in Bystander CPR by Year.
Note: * 2022 data were pooled for one-half of the year, spanning January 1 through June 30.
Abbreviation: CPR, cardiopulmonary resuscitation.
Exploratory Outcomes
In 2017, 27.3% of men (n = 15) and 21.7% of women (n = 10) received BCPR (OR = 1.35; 95%CI, 0.54-3.38). Excluding family and friends, 10.9% of men (n = 6) and 4.4% of women (n = 2) received “true” layperson BCPR (OR = 2.70; 95%CI, 0.51-14.24).
In 2018, 22.2% of men (n = 20) and 25.6% of women (n = 11) received BCPR (OR = 0.83; 95%CI, 0.36-1.94). Excluding family and friends, 7.8% of men (n = 7) and 4.7% of women (n = 2) received “true” layperson BCPR (OR = 1.60; 95%CI, 0.32-8.14).
In 2019, 29.3% of men (n = 22) and 11.4% of women (n = 4) received BCPR (OR = 3.22; 95%CI, 1.02-10.20). Excluding family and friends, 9.3% of men (n = 7) and 2.9% of women (n = 1) received “true” layperson BCPR (OR = 4.01; 95%CI, 0.48-34.86).
In 2020, 28.6% of men (n = 24) and 25.6% of women (n = 11) received BCPR (OR = 1.12; 95%CI, 0.50-2.49). Excluding family and friends, 9.5% of men (n = 8) and 4.7% of women (n = 2) received “true” layperson BCPR (OR = 2.13; 95%CI, 0.43-10.65).
In 2021, 32.0% of men (n = 31) and 20.8% of women (n = 11) received BCPR (OR = 1.79; 95%CI, 0.82-3.95). Excluding family and friends, 11.3% of men (n = 11) and 1.9% of women (n = 1) received “true” layperson BCPR (OR = 7.00; 95%CI, 0.87-56.22).
From January 1 through June 30 of 2022, 22.0% of men (n = 11) and 3.3% of women (n = 1) received BCPR (OR = 8.18; 95%CI, 1.00-66.98). Excluding family and friends, 8.0% of men (n = 4) and 0.0% of women (n = 0) received “true” layperson BCPR (OR = 6.72; 95%CI, 0.35-129.77).
Discussion
This retrospective chart review highlights significant gender disparities in BCPR following OHCA. Men in the study population were not only more likely to receive BCPR overall, but also more likely to receive it from a layperson unknown to them: a “true” bystander. In contrast, among those who received BCPR, women were more likely than men to have received CPR from a family member or friend. Despite this, women were still less likely overall to receive any BCPR, highlighting a consistent gap in prehospital intervention that persisted regardless of bystander type. These findings reflect the complex role gender plays in shaping who receives BCPR and from whom, reinforcing the need to further explore how these dynamics influence bystander response and patient outcomes.
This study’s investigation sheds light on gender-based disparities in BCPR within an under-served region: Camden, New Jersey USA. Building upon established research highlighting discrepancies associated with geography, socioeconomic status, and racial composition, this study acknowledges the broader challenges faced by communities with limited resources.Reference Sasson, Magid and Chan14-Reference Root, Gonzales, Persse, Hinchey, McNally and Sasson16 Complementary findings such as lower BCPR rates in low-income Black neighborhoods (OR = 0.49; 95%CI, 0.41-0.58) highlight the need to contextualize this study within broader disparities in BCPR delivery.Reference Sasson, Magid and Chan14 A thorough understanding of these disparities is essential to interpret the study findings within the broader challenges faced by under-served communities.
This study also highlights important areas for future exploration and improvement in out-of-hospital BCPR interventions. One key direction involves examining how gender dynamics influence bystander response, particularly in public settings. Prior research suggests that concerns about modesty and privacy may contribute to bystanders’ hesitation to perform CPR on women.Reference Blewer, McGovern and Schmicker2,Reference Liu, Ning and Eng Hock Ong8 Understanding the reasons behind these hesitations represents an important and under-explored area of research that could inform future efforts to reduce gender-based disparities in bystander intervention. Moreover, CPR training programs should incorporate scenarios that address patient modesty, equipping individuals to respond confidently and appropriately even when life-saving action may involve removing clothing in public.
Studies showing higher BCPR rates among male victims in public settings also highlight an opportunity to refine dispatcher scripts to better guide bystanders and help address gender-based disparities in BCPR delivery.Reference Blewer, McGovern and Schmicker2,Reference Liu, Ning and Eng Hock Ong8 As the first point of contact in OHCA events, emergency dispatchers play a critical role in facilitating dispatch-assisted CPR. Yet, most standardized scripts lack attention to factors such as gender, physical characteristics, or potential barriers faced by bystanders. While this study did not assess the prevalence of dispatch-assisted CPR by gender, the observed disparities highlight an opportunity for more tailored dispatcher guidance that acknowledges and addresses gender-specific challenges in bystander response.
Beyond gender-related factors, the broader context in which BCPR occurs (such as public health crises) also influences intervention rates. Although this study primarily focused on gender dynamics in BCPR, the impact of the coronavirus disease 2019 (COVID-19) pandemic on BCPR delivery also warrants consideration. Contrary to expectations that fear of viral transmission might reduce BCPR rates, the results showed a relatively consistent rate across the study period, with a slight increase in CPR provided by friends and family in 2021. This unexpected pattern suggests a potential resilience in BCPR rates, or a possible shift in public attitudes toward providing CPR during the pandemic. Further investigation into how COVID-19 influenced bystander willingness and whether these effects may persist in post-pandemic years would be a valuable extension of this work, for these insights could help clarify what drives or hinders bystander intervention and inform strategies to improve BCPR rates across diverse communities and settings.
This study’s findings highlight the need for both immediate action and continued research to better understand the factors contributing to gender disparities in out-of-hospital BCPR. Future studies could examine whether the gender of the bystander influences their likelihood to perform CPR, particularly in same- versus opposite-gender scenarios. Exploring how interpersonal dynamics, cultural norms, and community-specific factors shape bystander behavior may help inform more tailored and effective training programs. Finally, continued efforts in these areas are essential for developing interventions that address the complex drivers of disparity and improve BCPR delivery across diverse populations.
Limitations
As this was a single center study based on one urban EMS agency, generalizability to other agencies in various environments is limited. Data collection was limited to information documented in one EMS agency’s charting system by prehospital providers, introducing the potential for inaccuracies that could impact the results. The breadth of data could also be expanded, and the accuracy and precision of data collection and entry also offers room for improvement. In future studies, to ensure maximum accuracy, a second blinded researcher could verify all collected data and implement a strategy to resolve any conflict(s) that arose when verifying the data coding of each encounter. Additionally, exploratory outcomes were not corrected for multiple comparisons, and their confidence intervals were unadjusted and intended for hypothesis generation only. Confidence intervals for all reported outcomes, including primary and secondary analyses, were not adjusted for multiplicity and should be interpreted with caution. Finally, this study did not assess patient outcomes or compare outcomes based on gender or the type of BCPR received, though this represents an important avenue for future research.
Conclusions
This retrospective prehospital chart review highlights significant gender disparities in BCPR following OHCA. Men in the study population were more likely than women to receive BCPR overall, and more likely to receive it from a “true” bystander unknown to them. This under-examined trend adds to the growing body of literature on gender disparities in prehospital care and underscores the need for further research to identify underlying barriers and biases. Such investigations are essential for informing targeted messaging for lay responders, health care providers, and dispatchers, with the goal of promoting more equitable and effective prehospital interventions.
Acknowledgements
The authors extend their heartfelt gratitude to the dedicated EMS crews serving the Camden, New Jersey region, whose unwavering commitment to community well-being and swift response has been invaluable to the success of this research and patient outcomes.
Conflicts of interest/funding/disclaimer
The views and suggestions expressed in this manuscript are of the authors and not of the institution(s) they represent. No sources of support (external funding or otherwise) have been obtained for the conductance of this research. The authors have no financial disclosures to describe, and declare that there is no conflict of interest regarding the publication of this paper.
