Public knowledge of cardiovascular disease and response to acute cardiac events in three cities in China and India

Cardiovascular disease (CVD) is the leading cause of death and disability globally, responsible for over 17 million deaths in 2013, with China and India bearing the largest burdens. Despite a World Health Organization target of a 25% reduction in premature CVD mortality by 2025, progress in China and India may be insufficient without rapid system and population-level changes. While risk factor identification and modification are essential, numerous public health, health system and clinical interventions can reduce mortality from acute cardiac events such as acute myocardial infarction (AMI) and sudden cardiac arrest (SCA). Both require rapid recognition and coordinated care beginning at symptom onset. Increasing public awareness of responses to acute cardiac events, strengthening prehospital systems, and ensuring timely, evidence-based in-hospital treatment are critical. The Global HeartRescue project aims to improve outcomes for AMI and SCA through best practices, especially prehospital, and public education. To inform demonstration projects in China and India, a landscape assessment was conducted in Beijing, Shanghai, and Bangalore to measure public knowledge of CVD risk factors and AMI symptoms, CPR/AED awareness and training, and emergency service utilisation.

The authors situate the study within global targets for reducing CVD mortality and prior evidence that system-level and clinical interventions improve outcomes for AMI and SCA. They note extensive literature supporting early recognition, bystander intervention (CPR/AED), and organised systems of care for improved survival after cardiac events. However, data on public knowledge of CVD risk factors, AMI symptoms, and response to acute events are limited outside high-income countries. Prior studies suggest that inadequate symptom recognition contributes to delays in care, and that CPR/AED awareness and training are generally higher in high-income settings than in China and India, underscoring a knowledge gap the present study addresses.

Design: Cross-sectional descriptive study of knowledge, attitudes and practices (KAP) regarding CVD risk factors, AMI and SCA symptoms, CPR and AED awareness/training, and emergency service utilisation. Setting: Three megacities—Beijing and Shanghai (China) and Bangalore (India). Data collection periods: Beijing and Shanghai (April–June 2015); Bangalore (September–November 2015). Participants: Adults aged 18+. Components: (1) Structured household survey; (2) Semi-structured key informant interviews and focus groups with community members and patients. Sampling: - Beijing and Shanghai: Stratified random sampling targeting ≥3000 total households divided evenly across selected districts/counties (Beijing: Xicheng and Chaoyang; Shanghai: Changning and Chongming). Streets/townships stratified by distance to a survey hospital (four levels). One street/township per stratum; within each, four residential committees/villages selected by probability proportional to size; within each, 48 residents aged ≥18 selected by simple random sampling to meet age-sex quotas matching district/county distributions. - Bangalore: Stratified random sampling of 2400 households from the urban core. 80 wards selected by probability proportional to size, stratified by Socio Economic Classification (high/medium/low). One polling area per SEC stratum was randomly selected; 30 households per polling area sampled. One adult per household selected via Kish method; refusals replaced using right-hand rule. Ensured ≥10 respondents per gender in each area. Instruments and procedures: Trained research assistants administered local-language surveys electronically after written consent. Survey covered sociodemographics, CVD knowledge, CPR/AED awareness and training, and emergency services utilisation. Qualitative interviews/focus groups explored beliefs and experiences regarding health, acute CVD symptoms/response, and emergency care; participants sampled from survey areas (community) and from hospitals/nearby areas (patients). Interviews/focus groups were recorded, transcribed, and de-identified. Analysis: Quantitative—Descriptive statistics as percentages/fractions for each city separately. Regression models assessed sociodemographic determinants: Poisson regression with log link for counts of CVD risk factors and AMI symptoms named; logistic regression for CPR awareness (dichotomous). Separate models per city; predictors: sex, age, education; in Bangalore, income was also included. Statistical software: Stata SE 13.1; visualisation in Microsoft Excel 2013. Qualitative—Framework approach: open coding of a representative sample, development of a thematic framework, coding of remaining transcripts, identification of convergent/divergent themes. Ethics: Local IRB approvals in China and India; data de-identified for analysis at the University of Washington.

- Surveys completed: 5456 total across three cities. - CVD risk factor knowledge: • Beijing: 68% identified hypertension; around half identified high cholesterol, high blood glucose, and obesity; 56% identified excessive alcohol; 27% physical inactivity; 66% smoking. • Shanghai: Similar to Beijing, with notable differences—excessive alcohol 39%, physical inactivity 15%, smoking 44%. • Bangalore: 91% identified smoking (highest of any risk factor across cities); 64% excessive alcohol; ~<50% identified hypertension; 55% hypercholesterolaemia; only 20% identified high blood glucose; very few identified physical inactivity. - AMI symptom knowledge: • Proportion unable to name any symptom: Beijing 15%, Shanghai 18%, Bangalore 21%. • Most commonly named symptom: chest pain/discomfort (~60% in each city). • Bangalore: 57% reported pain/numbness or radiation to back/jaw/neck/arm/hand. • Other symptoms (diaphoresis, dizziness, nausea) were less frequently mentioned across cities. - CPR awareness/training: • Never heard of CPR: Bangalore 92%. • CPR trained: Beijing 26%, Shanghai 15%, Bangalore 3%. • Higher education strongly correlated with CPR knowledge. - AED recognition/willingness: • Recognition of AED (with a picture): Beijing 22%, Shanghai 15%, Bangalore 6%. • Willingness to use an AED after explanation: Bangalore 80% vs Beijing 13% and Shanghai 13%. • Among those previously CPR-trained, AED use was not covered in most trainings: Bangalore 81%, Beijing 67%, Shanghai 80%. - Emergency service utilisation (past 12 months): • ED visit: Bangalore 1.3% (32/2400), Beijing 5.7% (86/1520), Shanghai 6.6% (101/1536). • Mode of transport among ED users: self-transportation predominated—Bangalore 68.8%, Beijing 91.9%, Shanghai 94.1%; ambulance use was low—Bangalore 21.9%, Beijing 8.1%, Shanghai 5.0%. - Determinants of knowledge: • Education positively associated with naming more CVD risk factors in all cities; strongest in Shanghai (IRR 2.95; 95% CI 2.54–3.43 for university/college education). • Older age associated with naming more risk factors in Beijing, but not in Shanghai or Bangalore. • AMI symptoms: Higher education associated with more symptoms named in Beijing and Shanghai; in Bangalore, higher education associated with fewer symptoms named (IRR 0.88; 95% CI 0.82–0.96), persisting after adjusting for income (IRR 0.91; 95% CI 0.84–0.98). - Qualitative insights: • Many learned of CPR from TV/media; interest in training existed but fear of causing harm, doing it incorrectly, and legal ramifications deterred action. • Perceived slow EMS response (traffic), limited ambulance availability/supplies, and limited prehospital provider capabilities; concerns about prehospital care quality. • In Bangalore, patients often contact personal doctors before hospital care; public education focuses more on prevention than on acute event recognition/response.

The study reveals modest knowledge of CVD risk factors and AMI symptoms and particularly low CPR/AED awareness and training in Beijing, Shanghai, and Bangalore. These gaps likely contribute to delays in care and low utilisation of time-sensitive emergency services, undermining optimal outcomes for AMI and SCA. Compared with reports from higher-income settings (e.g., Singapore, South Korea, USA, Japan), risk factor and symptom recognition and CPR/AED familiarity were substantially lower in all three cities. Education consistently correlated with knowledge and training, suggesting that targeted educational initiatives, including integration into primary/secondary schools and community outreach to lower-education groups, may be effective. Cultural, social, financial, and legal barriers appear to reduce willingness to perform CPR or use AEDs and to use EMS; addressing perceived quality, legal protections, and affordability could increase bystander intervention and EMS use. Improving public knowledge, bystander response, and trust in prehospital care aligns with known determinants of survival after AMI/SCA and directly addresses the study’s aim to inform interventions under the Global HeartRescue initiative.

Knowledge of CVD risk factors and AMI symptoms in three major cities in China and India was low to modest; CPR awareness/training was poor, and AED awareness was minimal. Low ED/EMS utilisation and concerns about prehospital care quality were common. To reduce AMI and SCA mortality, interventions should include sustained public education on acute cardiac symptoms and response, expansion of CPR/AED training (including school-based programs and community outreach), strengthening EMS capacity and quality, and strategies to mitigate legal and financial barriers. These baseline data provide actionable insights to guide the Global HeartRescue demonstration projects and future system improvements.

- Generalisability: Each city’s metro population exceeds 10 million; the sampled populations, while methodologically selected, are small in comparison and may not be fully representative. - Sampling constraints: Financial and logistical limitations may affect representativeness; qualitative participants were convenience samples, so qualitative findings are presented descriptively. - Measurement: Potential cultural and language misunderstandings despite local partnerships and translations could lead to misinterpretation of questions and under- or overestimation of true knowledge. - Data consistency: Minor discrepancies in reported sample counts across text and tables may reflect reporting/rounding issues.