This study aimed to explore characteristics and to quantify the underlying motivational factors for joining a CPR lay responder system. Our main findings were that CPR instructors were the most important information source to potential lay responders and even though healthcare personnel were the most represented occupation, lay responders came from diverse occupational backgrounds. Six out of ten lay volunteers in the study were women and the age group 25–39 was overrepresented among the total study population (45%). Motivation to join the lay responder system was not purely intrinsic or extrinsic, but intrinsic motivation, values, an inner belief in doing good for others, dominated. The most important extrinsic motivation categories were reciprocity, a belief that doing good for others will come back to the volunteer later on in life, and self-esteem, a way of increasing one’s own feelings of self-worth and self-esteem.
Possible finding mechanisms
Most lay responders received their CPR education through their work. This may be due to the fact that CPR training has become a natural part of the working life in Sweden . A large proportion of the lay responders have a background in healthcare, police, and fire services where CPR training is a repeated element, but a significant share of the investigated population has a variety of professions, which indicates that recruiting should aim towards the public in general. Healthcare personnel is the largest group of occupations and despite or because of the nature of their task assignments during work, they are motivated to become lay responders off duty. Most lay responders in the study, had a high level of education; 66% had post-secondary education compared with the national average of 44% in people 25–64 years of age , and students were the second largest group of occupation, which indicates that recruiting campaigns aiming at workplaces that require higher education or towards colleges and universities might be succesful.
Most lay responders learned about the lay responder system through their CPR instructor and if such participants were to be asked a direct question about joining a lay responder system, recruitment might be additionally successful. This corresponds well with Busell and Forbes’s  study that people are four times as likely to volunteer when they received a targeted question than when they were not. Education initiatives vary around the world; CPR instructors can for example be a teacher, ambulance personnel, students, or a family member . Apart from CPR instructors, participants in this study learned about the lay responder system through friends, family, and work colleagues. Social media, in this case information and storytelling through Facebook , had five times more impact on recruiting than more traditional media such as articles in newspapers, indicating that campaigns in social media can play an important role when recruiting lay responders.
Values as the most important motivational category for volunteering is consistent with previous studies, including the study by Esmond and Dunlop [11, 26,27,28,29,30]. Appealing to intrinsic and altruistic motivational factors as values, emphasizing the importance of lay responder action for successful resuscitation in OHCA, might therefore be of significant importance when recruiting lay responders.
Reciprocity, being the second most important category, also corresponds with the result in the study by Esmond and Dunlop . In our study, the category is most important among the group other occupations and is both intrinsic and extrinsic. The tagline “the effort you put in today will bring good things later on in life” could be used in recruitment campaigns, thus reinforcing the idea that if you expect help when in need, you also need to be a helper.
The category self-esteem seems to be more important for motivation and determination for volunteering in our study than in the Esmond and Dunlop survey , which might be explained by the fact that the project has run great interest and that the commitment is a lifesaving act. Phung et al. , state that self-esteem and personal satisfaction from helping others were an important factor for motivation for becoming and remaining a lay responder (defined in that study as community first responder, or CFR). The feeling of meaningfulness of being a part of a lay responder system ought to be strong, as the act of CPR or bringing an AED to a patient can make the difference between life and death. It corresponds also with Grouzet et al. , arguing that people want to feel effective and have a feeling of mastering their world by searching for optimal challenging activities.
Recognition was more important for motivation in the Esmond and Dunlop survey , which may be due to the fact that lay responder systems require less contribution in terms of time and effort.
Phung et al., also identified the lay responder engagement as a route towards a future career as a health professional . In our study, career development scored low and that might be explained by the differences in setting, where most CRFs also are trained to respond to other emergency calls than OHCAs and thereby gain more professional contacts and a better insight to health professions and EMS than most lay responders in our study. Barry et al.  also identified lay responders that were motivated based on past experiences. That corresponds with the category reactivity, which scored lowest among the motivational categories in our study. This might be explained by the fact that inclusion criteria in the Barry et al. study was to have personal experience of OHCA situations.
The overall lower scores among the lay responders in our study compared to the Esmond and Dunlop study  could be explained by the reason that a longer commitment requires a higher level of motivation.
Most studies on motivation among lay responders acting on OHCAs investigated community first responders (CFRs). Motivation based on intrinsic motivational factors, values, and extrinsic motivational factors, self-esteem, correspond well with the motivational factors for the lay responders in our study. Past experiences (reactivity) and career development are factors that appear more important as motivation for CRFs than lay responders in our study. This could be explained by the different settings of the lay responders. Most members of CRF groups plan their participation ahead of time and work on a schedule. They sometimes work in pairs, are trained in basic life support, and are handed a dedicated alert phone that receives a limited range of dispatched emergency calls. Also, most CFR groups work in rural areas [29, 30]. The subjects in our study participate in the dispatched EMS chain by being alerted to their personal mobile phone, if they happened to be in the geographic area where a suspected OHCA occurred, and they represent both rural and more densely populated areas. Hence, their actions are not planned ahead and could take place at any time.
The decreasing mean scores for career development with each increasing age group in the stratification based on age (Additional file 5: Figure S1) suggests that this motivation becomes less important with increasing age. Note that the mean scores for certain motivational categories such as career development and understanding where higher for the oldest age groups, 65 years and older. These results must be interpreted with caution as these volunteers only made up 2.4% of the study population. Intuitively, young volunteers that are either students or in the early stages of their careers are likely to value the experience that volunteering will yield their careers. A similar pattern for career development was presented in Ho, You and Fung’s research ; the authors described that younger volunteers were more motivated to improve their future employment prospects than older volunteers. Additionally, greater importance for understanding in the younger volunteers suggests that these volunteers are motivated to learn through the experiences from volunteering. A large proportion of the volunteers were also healthcare professionals. Therefore, career development and understanding are likely strong motivators amongst the younger volunteers with careers in healthcare.
Self-esteem was also a stronger motivator for younger volunteers which corresponds with Cho, Bonn and Han’s research . These results suggest that younger volunteers are in part motivated to become first responders with the expectation that the experience will elevate their self-worth. Here again, the higher means score of the age group 65–74 years is possibly misleading.
Social interaction was valued more in the older age groups. However, there were very few volunteers in these age groups, thus these results may not be representative of a greater population.
Most patients who suffer from OHCA do not survive [34, 35]. The chance to survive increases with fast response, early treatment with CPR and the use of an AED [36, 37]. However, in the last 30 years, EMS systems response times have increased . Thus, involving lay responders could be an important part in efforts to increase survival rates and is recommended both by AHA and ERC.
As CPR instructors seemed to be the most common recruiter of lay responders, focus and support especially in regards to CPR instructors should be a priority when recruiting volunteers to a lay responder system. It is also important that CPR instructors have knowledge about their important role as recruiters and what motivates lay responders to join a lay responder system in order to increase participation. A mandatory question about participation to a lay responder system might be a successful recruitment strategy.
Additionally, this study showed that the lay responders are largely represented by younger individuals in the age group 25–39 years. Therefore, information campaigns through social media could be effective in recruiting younger responders; this corresponds with the annual report on the Internet and social media usage in the Swedish population . However, an examination of the subjects with other occupations showed that CPR training through work and the CPR instructor were effective recruitment channels. This further confirms the CPR instructors’ crucial role in recruitment. Thus, information campaigns in social media can likely be an additional tool useful to an already successful concept.
Though the importance of different motivation categories differed among the clusters, all clusters showed that motivation categories with largely intrinsic components, e.g., values and reciprocity, had the greatest impact on motivation for the lay responders. Highly valued motivations with largely extrinsic components, e.g., reactivity, did not exist, and that suggests that lay responders are less likely to have extrinsic factors as their motivation. This implies that focusing information campaigns on intrinsic factors could be important for successful recruitment. This could be exemplified by the difference a lay responder in close vicinity to an OHCA victim can make combined with real-life-stories of OHCA survivors that may increase motivation, self-determination, and commitment.
Among the statements in the survey, “Being appreciated by the organization behind SMS-lifesavers is important to me” scored above neutral (M 3.56; SD 1.15) with 39% of the population responding agree or strongly agree, which suggests that there is a considerable group of lay responders that need some type of feedback and attention. Providing recognition for skills and contribution is a major challenge for managers of lay responders in a lay responder system. The result of the survey identifies the need for finding ways to formally and perhaps informally recognize and reward lay responders. One way to address recognition could be by providing a small stipend  or a thank you note . Another way for providing recognition could be providing an object that can be made visible to others, like a bumper sticker or a keychain, when joining the lay responder system.
An interesting finding from the cluster analysis was that clusters three and four were smaller groups and had a different ranking of the motivation categories. The level of education differed the most between the clusters, with a majority of the volunteers in clusters three and four who had completed secondary education, whilst clusters one and two had mostly completed post-secondary education. Thus, level of education may have an association with motivation, which in turn can be important for the recruitment of more volunteers.
In order to better understand motivation behind volunteering to a lay responder system such as SMS-lifesavers, studies that investigate e.g. whether motivation changes over time and/or according to the frequency of alerts, and what would motivate those with CPR knowledge who not respond to recruiting campaigns, would be of benefit in the future, both quantitatively and qualitatively.
The survey was distributed to a relatively small group of lay responders in the western part of Sweden and the result might differ from other regions and countries, although the region includes both urban and rural areas. The response rate was 58%, which may affect the validity of the results; however, mean response rate in similar studies are between 43–53% and survey response rates have generally declined over the past years [41, 42]. General characteristics such as gender and age do not differ significantly between the total population and the study cohort; however, motivation might diverge between the two groups.
To our knowledge, Esmond and Dunlop’s  research is the largest study of volunteer motivations. The VMI is validated, but the scoring guide and methodology have some weaknesses. Translating answers that are not equidistant to a Likert like scale, even with ordinal answers, only indicates trends in the result, not an entirely true number.