Facilitating access to cardiopulmonary resuscitation training in high-risk underserved communities: a realist evidence synthesis

Members of the public are vital in improving survival from an out-of-hospital cardiac arrest (OHCA) by calling Emergency Medical Services, performing cardiopulmonary resuscitation (CPR) and using a defibrillator. However, some parts of England, with higher incidence of OHCA with lower rates of lay rescuer CPR are usually more socioeconomically disadvantaged and ethnically diverse areas. Increasing access to resuscitation skills training may help address this disparity, however little is known about the factors influencing people’s decisions to intervene and how best to engage people from these communities. We aimed to develop initial realist programme theory (IPT) of how, why, in which contexts and with what impacts interventions can engage people from minoritized ethnic groups in CPR training. This theory provides information on contexts in which mechanisms (resources and people’s responses to them) might work to produce outcomes that contribute to facilitating training access. Using ITPs with formal behaviour change theory is an innovative approach. Together they can provide detailed theory to inform intervention development. We conducted a realist evidence synthesis of published literature and primary data collected from four workshops with South Asian and Black African and Caribbean communities in socioeconomically disadvantaged areas of England. The resulting IPT is expressed as eight context-mechanism-outcome (CMO) configurations. The IPT covers chronological stages that must be addressed to facilitate underserved community members’ participation in resuscitation skills training; 1) gaining access to communities and overcoming mistrust of people perceived as outsiders or establishment figures; 2) addressing practical and contextual obstacles to training attendance and 3) creating a training environment that promotes engagement and uses activities informed by behaviour change techniques that encourage deeper and active learning. Building trusting and collaborative relationships with influential trusted voices from communities runs through all chronological stages. Addressing obstacles to training attendance and creating a training environment that includes culturally informed 2-way discussion of concerns, opportunity to rehearse dealing with potential barriers to acting as well as practical skills training all informed by behaviour change techniques could contribute to successful training. We contribute nuanced theoretical understanding taking into account contextual factors, of what might work for whom, how and why to facilitate access to resuscitation skills training for underserved communities to inform future intervention development, implementation and evaluation. Building trust and collaborative working with communities underpin this theory. ISRCTN. Registration date 28/03/2023. https://doi.org/10.1186/ISRCTN90350842 .