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

Cardiovascular disease (CVD) is a leading cause of death globally, with China and India carrying a significant burden. The World Health Organization (WHO) aims to reduce CVD-associated premature mortality by 25% by 2025, but achieving this in China and India requires substantial changes. While risk factor modification is crucial, improving responses to acute cardiac events like AMI and sudden cardiac arrest (SCA) is equally important. Rapid recognition of symptoms and coordinated care are essential for positive outcomes. The Global HeartRescue project seeks to improve outcomes by implementing best practices and increasing public awareness. This landscape assessment, conducted in Beijing, Shanghai, and Bangalore, examines public knowledge of CVD risk factors, AMI symptoms, CPR, AEDs, and emergency service utilization to inform the project's demonstration projects.

Existing literature highlights the multitude of interventions shown to improve patient outcomes for AMI and SCA, emphasizing the importance of rapid recognition and coordinated care from symptom onset. Studies underscore the need for increased public awareness of how to respond to acute cardiac events, improved prehospital systems, and timely evidence-based hospital treatment. However, data on public knowledge of CVD, AMI symptoms, and appropriate responses are limited outside high-income countries. This study aims to fill this gap by providing baseline data from three megacities in China and India.

This cross-sectional descriptive study used a household survey (1524 in Beijing, 1537 in Shanghai, 2400 in Bangalore) and qualitative data (focus groups and interviews) to assess knowledge, attitudes, and practices (KAP) regarding CVD risk factors, AMI and SCA symptoms, CPR and AED awareness and training, and emergency service utilization. Stratified random sampling was employed in all three cities, ensuring representation across various socio-economic strata. The household survey collected socio-demographic information and data on CVD knowledge, emergency service use, and related attitudes. Qualitative data were analyzed using a framework approach, identifying themes related to patient and community perceptions of CVD and emergency healthcare. Statistical analyses (Poisson regression for CVD and AMI knowledge, logistic regression for CPR awareness) were performed to identify socio-demographic determinants of knowledge.

Hypertension was the most commonly recognized CVD risk factor in Beijing and Shanghai (68% and 67%), while smoking (91%) and excessive alcohol consumption (64%) were most prevalent in Bangalore. Chest pain/discomfort was the most common AMI symptom identified across all cities (around 60%), but significant proportions couldn't name any symptoms (15% in Beijing, 18% in Shanghai, 21% in Bangalore). CPR training rates were low (26% in Beijing, 15% in Shanghai, 3% in Bangalore), and AED recognition was even lower (<25%). Emergency service utilization was also very low, with many expressing concerns about prehospital care quality. Regression analyses showed a positive correlation between education and CVD/AMI knowledge in Beijing and Shanghai, but an inverse relationship in Bangalore. Qualitative data highlighted limited patient-provider interaction regarding AMI symptoms and fear of legal repercussions and/or causing harm hindering CPR/AED usage.

This study reveals significant gaps in CVD knowledge, AMI symptom recognition, CPR training, and AED awareness in these three megacities, similar to knowledge levels in high-income countries in the 1980s and 1990s. This lack of awareness is concerning, given evidence linking delayed care to inappropriate symptom attribution. The low rates of CPR and AED awareness and training are particularly worrying given their impact on SCA survival. Education and training initiatives should target various groups, including those with limited education. Furthermore, addressing cultural, social, financial, and legal barriers to CPR/AED use and accessing emergency care is crucial. Concerns regarding prehospital care quality and financial burdens need to be addressed to increase emergency service utilization.

This study highlights the urgent need for comprehensive interventions to improve public knowledge of CVD and response to acute cardiac events in China and India. Future interventions should focus on increasing public awareness of CVD risk factors and AMI symptoms, promoting CPR and AED training, addressing barriers to emergency care access, and enhancing the quality of prehospital services.

The study's sample size, while substantial, was still relatively small compared to the megacities' populations. Qualitative data were gathered using convenience sampling, limiting generalizability. Cultural and language barriers could have also influenced participant understanding of survey questions, although local partners were involved in data collection and translation. These factors could have affected the representativeness of the findings.