How best to train kids in basic life support: a literature review

Abstract

Background

Bystander intervention is known to be the most important factor in the survival chain for out-of-hospital cardiac arrest. However, bystander cardiopulmonary resuscitation (CPR) rates remain low—mainly due to a lack of training. Implementing basic life support (BLS) training in schools is a key aspect of increasing bystander intervention.

We reviewed the literature on BLS training methods for schoolchildren and sought to identify the methodological elements that appeared to be the most effective in terms of the acquisition and retention of knowledge, practical skills, and attitudinal skills.

Methods

We searched the MEDLINE database (via PubMed) for relevant articles published between from January 2015 to January 2022. Articles on BLS training in children were selected if the primary objective was determine the effectiveness of the training method(s) used.

Results

Of the 1,098 publications identified, 28 were selected and reviewed. Half of the studies had a randomized, controlled design, the study sample size ranged from 57 to 1,917. Hands-on practice was included in 26 of the 28 studies, and the main training session lasted for 75 to 120 min. Hands-on practice gave better results than no practice. Learning tools promoted acquisition, and refresher training sessions appeared to be of value.

Conclusions

The results of our literature review showed that the conventional training pattern used with adults (i.e. theory, demonstration, and practice) is applicable to children if all the components are adapted for this population. Further studies of the development and evaluation of BLS training for young children are required.

Background

Out-of-hospital cardiac arrest (OHCA) is a health issue worldwide. The incidence of OHCA is reportedly 84.0 (per 100,000 person-years) in Europe, 110.8 in North America, 52.5 in Asia, and 112.9 in Australia [1, 2]. Worldwide, the 30-day survival rate is about 7.6% [3]. The time from collapse to cardiopulmonary resuscitation (CPR) is one of the main determinants of survival [4, 5]. Moreover, early recognition, calling for help, and early CPR are acknowledged to the most important points in the survival chain [6]. In fact, bystander CPR before arrival of a paramedical unit or a mobile intensive care unit is associated with significantly higher survival rate [3, 7–11]. The bystander CPR rate differs markedly from country to another; in Europe, this rate ranging from 6% in Romania to 45% in France and more than 70% in The Netherlands [12]. While it is difficult to obtain exact data on the proportion of people trained in BLS, a trained person is 10 times more likely than a person with no training to initiate resuscitation [13, 14].

Since the 2005 International Liaison Committee on Resuscitation include a 30:2 compression-ventilation ratio in basic life support (BLS) in its guidelines to simplify practices, which thus facilitated training in BLS [15]. Given the low CPR rates, BLS training is one of the most important points in the European Resuscitation Council’s latest guidelines [16]. When BLS training is not mandatory, it is difficult to involve large proportions of the population. For BLS training to be as effective as possible, it is necessary to focus on efficiency. Hence, one can reasonably consider the inclusion of BLS training in school education; today’s schoolchildren are tomorrow’s adults and potential OHCA bystanders. Several countries have already implemented BLS training at school, as a key factor in increasing bystander intervention [17–19]. However, there are few data on which methods for BLS training at school are the most effective.

The objective of the present literature review was therefore to describe BLS training methods for schoolchildren and to identify methodological factors and tools associated with the acquisition and retention of knowledge, practical skills, and attitudinal skills.

Method

Study design

The literature review’s research question was defined by applying the Population, Intervention, Comparison and Outcomes (PICO) method [20]: in schoolchildren (P), which BLS training method (I) appears to be the best (compared with no training or with other methods (C)) in terms of knowledge about BLS, CPR quality, and skill retention (O)?

Inclusion and exclusion criteria

P: we only included studies whose participants were all under the age of 18.

I: we examined all BLS training methods dealing with the first three stages of the survival chain, as long as the study’s primary objective was to determine the method’s effectiveness.

C: we included all studies comparing different methods of training or comparing trained and not trained participants.

O: we included only studies whose primary outcome was the quality or retention of BLS skills.

Type of study: we included original articles published in English, Spanish, or French.

Exclusion criteria: we excluded studies of adults (aged 18 or over), studies of students in the health care field (medicine, pharmacy, nursing, odontology, etc.), and studies of advanced life support systems or paediatric CPR.

The data were extracted, organized, summarized, analyzed and reported. The reporting model was a modified version of the one used by Gonzalez-Salvado et al. in their review of BLS training for adults [21].

Search strategy

We collected article through MEDLINE (Pubmed) and Web of Science. We used medical subject headings (MeSH) and the Boolean operators “OR”/“AND” to search the MEDLINE database (via PubMed) for relevant articles published between January 2015 and January 2022. The search query was: “cardiopulmonary resuscitation” OR CPR OR"First Aid"OR"lifesaving skill*"OR"life-saving skill*"OR"basic life support"OR BLS) AND (“Teaching” OR learn* OR train* OR educat* OR instruct*) AND (bystand* OR laypeople OR layperson* OR witness* OR “child” OR “adolescent”) AND (evaluat* OR assess* OR analys*)”. The specific MeSH terms were cardiopulmonary resuscitation; teaching; child; and adolescent. The same terms (without [MeSH] terms) were used to search the Web of Science.

Study selection

We first selected articles on the basis of the title and then the abstract. Articles that met all the inclusion criteria and none of the exclusion criteria were selected for full-text assessment. We thus determined whether or not the articles should be included in the review. The review was described in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA; Fig. 1) [22]. Three researchers made this process in order to limited discrepancies.

Fig. 1.

The PRISMA flowchart

Results

Search results

The search strategy described above identified 1,359 records. 261 duplicate records were removed, and 996 records were excluded on the basis of the title. Of the 102 articles chosen for the abstract review, 66 met at least one exclusion criterion. Of the 36 articles chosen for a full-text assessment, the main reasons for exclusion were a lack of information (n = 2), no targeted outcomes (n = 2), the wrong patient population (n = 2), and lack of the full-text publication (n = 2). After the full-text assessment, 28 articles met the inclusion criteria and were included in the review (Fig. 1).

Type of study and participants’ characteristics

There were 12 randomized, controlled studies and 5 nonrandomized, controlled studies (Table 1). The number of groups per study ranged from 1 to 4, and 56 groups were evaluated in all. The study sample size ranged from 57 to 1,917. The schoolchildren’s age ranged from 5 to 18. Of the 28 studies reviewed, 15 were carried out in Europe, with 8 in Asia, 4 in North or South America, and 1 in Africa.

Table 1.

Characteristics of the studies and the participants

First author and year of publication	Country	RDZ	CT	Number of groups	Total sample size	Group sizes	Population	Age a,b
Tanaka, 2020 [23]	Japan	+	+	2	57	30/24	High school students	17.7 ± 0.7/17.5 ± 0.5
Martínez-Isasi, 2021 [24]	Spain	+	+	2	62	32/30	11-year-old schoolchildren	11.86 ± 0.54
Abelairas-Gomez, 2021 [25]	Spain	+	+	3	472	146/124/202	8- to 12-year-old schoolchildren	Not reported
Beck, 2015 [26]	Germany	+	+	2	935	471/466	Secondary school students	14.0 ± 1.1/13.9 ± 1.1
Monteiro, 2021 [27]	Portugal	-	-	1	392	N/A	7- to 12-year-old schoolchildren	8.9 ± 0.6
Tony, 2020 [28]	Brazil	-	-	1	335	N/A	Elementary school attendees	13.2 ± 1.2
Aguila, 2019 [29]	Spain	-	-	1	1043	N/A	Schoolchildren	12.7 ± 0.7
Kua, 2018 [30]	Singapore	-	-	1	1196	N/A	11- to 17-year-old schoolchildren	14
Li, 2018 [31]	China	-	-	1	1093	N/A	Primary and secondary schoolchildren	Not reported
Ballesteros, 2020 [32]	Spain	-	+	2	326	113/213	Secondary school students	15.6 ± 0.7
Lukas, 2016 [33]	Germany	-	+	4	261	39/39/51/48	Secondary school students	Not reported
Nord, 2016 [34]	Sweden	+	+	2	1426	720/706	13-year-old schoolchildren	Not reported
Onan, 2019 [35]	Turkey	+	+	3	77	26/26/25	17- to 18-year-old student	Not reported
Otero-Agra, 2019 [36]	Spain	+	+	4	489	151/140/109/89	12- to 16-year-old schoolchildren	13.51 ± 1.15
Kitamura, 2016 [37]	Japan	-	-	1	1917	N/A	10- to 12 schoolchildren	11.1 ± 0.7
Kesici, 2021 [38]	Turkey	+	+	2	140	70/70	High school students	Not reported
Pivac, 2021 [39]	Slovenia	-	+	3	762	244/254/264	12- to 15-year-old schoolchildren	12.5/13.5/14.5
Wingen, 2018 [40]	Germany	+	+	2	424	207/217	14- to 18-year-old schoolchildren	15 [13, 15]
Semeraro, 2017 [41]	Italy	-	-	1	65	N/A	High school students	16 ± 1
So, 2020 [42]	China	-	-	1	128	N/A	12- to 15-year-old schoolchildren	Not reported
Tsai, 2019 [43]	Taiwan	-	-	1	336	N/A	Middle school students	Not reported
Varela-Casal, 2021 [44]	Spain	+	+	4	237	61/74/46/55	5- to 8-year-old schoolchildren	Not reported
Vetter, 2016 [45]	US	-	+	2	412	182/230	High school student	15.8 ± 1.2/16.1 ± 1.4
Gabriel, 2019 [46]	Nigeria	-	-	1	210	N/A	Secondary schoolchildren	17.0 ± 1.5
Yeung, 2017 [47]	UK	+	+	3	81	27/25/29	12- to 13-year-old schoolchildren	Not reported
Zeleke, 2019 [48]	US	-	+	3	160	53/56/51	12-year-old schoolchildren	Not reported
Suss-Havemann, 2020 [49]	Germany	+	+	2	600	307/293	High school student	12 ± 1
Schmid, 2018 [50]	Costa Rica	-	-	1	308	N/A	11- to 18-year-old schoolchildren	Not reported

BLS Basic life support, CT Controlled, N/A Not applicable, RDZ Randomized

^aAge is expressed as the mean ± standard deviation or the median [interquartile range]

^b"/"indicates that the data are described for each study group and not overall

The BLS training methods

Most studies included CPR (n = 27); half included chest compression (CC) only (n = 14), and half included CC and ventilation (CC-V; n = 13) (Table 2). Hands-on practice was almost always included (n = 26), and only 2 studied did not include any practical training. Use of an automated external defibrillator (AED) was included in 12 studies. Feedback devices were rarely included (n = 8). We also noted the use of a manikin feedback device (n = 4), a smartphone application (n = 2), virtual reality technology (n = 1), and training cards (n = 1). Most of studies (n = 18) featured the three conventional training steps (theory, a practical demonstration, and practical training). Self-instruction was rarely used (n = 8) and included video self-instruction (n = 5), a smartphone application (n = 2), a video game or virtual reality (n = 2), and music (n = 1). Only 2 studies investigated refresher training sessions. In most studies, the most frequent duration of the training session was 75–120 min (n = 11), followed by 45–60 min (n = 8), 125–180 min (n = 5), and 30 min (n = 2).

Table 2.

BLS training methods

Study	Training method [average duration in minutes]				CPR	AED use	Hands-on practice	Feedback devices	I:p ratio a
Tanaka, 2020 [23]	Practice While Watch (PWW) session on Quality of CPR (QCPR) manikins (BLS training video and skill practice) led by a physical education teacher with no background as a healthcare professional and no experience of teaching CPR [49]	PWW session on QCPR manikins (BLS training video and skill practice) led by a physical education teacher with a paramedic licence and more than 10 years of experience teaching CPR [49]			CC	-	+	Manikin	1:30/1:24
Martínez-Isasi, 2021 [24]	Knowledge acquisition session and practical session (6-min compressions in 2-min CRP training cycles in 3 sessions: continuous CC on a manikin with real-time feedback, CPR sequence and CC on a simple manikin and execution of the complete BLS sequence on a simple manikin) [100]	Knowledge acquisition session and practical session (6-min compressions in 1-min CRP training cycles in 3 sessions: continuous CC on a manikin with real-time feedback, CPR sequence and CC on a simple manikin and execution of the complete BLS sequence on a simple manikin) [100]			CC-V	+	+	Manikin	1:10
Abelairas-Gomez, 2021 [25]	Control group: Knowledge acquisition session and practical session (BLS sequence, CO-CPR on a basic manikin, and CO-CPR on a QCPR manikin) [100]	Standard group: Knowledge acquisition session and practical session (BLS sequence, CO-CPR on a basic manikin and CO-CPR on a QCPR manikin) [100] + one annual BLS retraining session (a theory-based overview of the BLS sequence and practical CPR training) [49] = [150]	Rolling refresher group: Knowledge acquisition session and practical session (BLS sequence, CO-CPR on a basic manikin and CO-CPR on a QCPR manikin) [100] + BLS rolling-refreshers every 4 months, annual BLS retraining (BLS sequence and practical CPR training) [4] = [125]		CC	-	+	Manikin	1:20–30
Beck, 2015 [26]	Peer-led group: lecture by a physician, BLS training by peer-instructors, and rotation as a class among the three stations “Assessment”, “Handling an AED”, and “Demonstration of treatment-options of the ambulance” [180]	Professional-led group: lecture by a physician, BLS training by professional-instructors and rotation as a class among the three stations of “Assessment”, “Handling an AED”, and “Demonstration of treatment-options of the ambulance” [180]			CC	+	+	-	2:10–14/1:10–14
Monteiro, 2021 [27]	Medical students provided a BLS lecture and then hands-on training for CPR on a stuffed animal and the recovery position [120]				CC	-	+	-	2:12–25
Tony, 2020 [28]	Knowledge transfer and a practical approach on mannequins, followed by a practical session [75]				CC-V	-	+	-	-
Aguila, 2019 [29]	A lecture and a practical session [180]				CC-V	-	+	-	1:8
Kua, 2018 [30]	A video and CPR practice [44]				CC	+	+	-	-
Li, 2018 [31]	A video and CPR practice [Not reported]				CC-V	-	+	-	-
Ballesteros, 2020 [32]	Theory-based group: a lecture only [60]	Practical group: a lecture and practical training [120]			CC-V	-	+	-	-
Lukas, 2016 [33]	Physician-trained/training continued group: theory-based lessons from an emergency physician and CPR training, once a year for 6 years [180]	Physician-trained/training paused group: theory-based lessons from an emergency physician and CPR training, once a year for 3 years [180]	Teacher-trained/training continued group: theory-based lessons from a teacher and CPR training, once a year for 6 years [180]	Teacher-trained/training paused group: theory-based lessons from a teacher and CPR training, once a year for 3 years [180]	CC-V	-	+	Manikin	-
Nord, 2016 [34]	App-based group: independent practice by using a smartphone application and a training manikin [29]	DVD-based group: practice CPR based on instructions from a DVD [49]			CC-V	-	+	-	1:14–29
Onan, 2019 [35]	Group A: a lecture only [80]	Group B: video-based instruction and practice on a manikin [80]	Group C: Video-based instruction, practice on a manikin, and smartphone-application-assisted feedback [80]		CC-V	-	+	Mobile-app	-
Otero-Agra, 2019 [36]	GAM group: a theory-based training video and practice on a manikin in teams of four students. A practical manikin competition with valuations of the results affecting the grades [49]	EVA group: a theory-based training video and individual practice on a manikin. Marks on CPR test quality affecting grades [49]	VFC group: a theory-based training video and individual practice on a manikin. The training activity did not affect grades and the trainees did not receive marks [49]	TC group: a theory-based training video and individual practice on a manikin, with no visual feedback. The training activity did not affect graded and the trainees did not receive marks [49]	CC	-	+	Little Anne mobile app	1:20–30
Kitamura, 2016 [37]	A lecture and practice [44]				CC	+	+	-	-
Kesici, 2021 [38]	Group A: a lecture and practical training led by a peer instructor trained by health professionals [120]	Group B: a lecture and practical training led by peer instructor trained by their peers (group A instructors) [120]			CC-V	+	+	-	1:9
Pivac, 2021 [39]	Seventh grade group: theory-based and practical training [120]	Eighth grade group: theory-based and practical training [120]	Ninth grade group: theory-based and practical training [120]		CC	+	+	-	-
Wingen, 2018 [40]	Intervention group: Education on theory and CPR skills, and a practical CPR training session [90]	Control group: Education on theory and CPR skills [90]			CC-V	-	+	-	-
Semeraro, 2017 [41]	2-min CC on a manikin with no feedback, 2 months later, a CC competition with Relive technology including visual feedback [Not reported]				CC	+	+	Relive	-
So, 2020 [42]	Theory-based discussion, a teaching video on CO-CPR/AED use and practical session [95]				CC	+	+	-	1:10
Tsai, 2019 [43]	A lecture and a practical session [49]				CC	+	+	-	1:24–32
Varela-Casal, 2021 [44]	The Rescube group: a lecture telling a CPR story using Rescube and a practical session on a cuddly toy [60]	The Endless Book group: a lecture telling a CPR story using Endless Book and a practical session on a cuddly toy [60]	The cuddly toy group: a lecture telling a CPR story with no particular learning tool and a practical session on a cuddly toy [60]	The manikin group: a lecture telling a CPR story with no specific learning tool and practical session on a manikin [60]		-	-	-	1:9
Vetter, 2016 [45]	Control group: the usual health education class CPR program [Not reported]	Study group: the usual health education class CPR program, development of innovative programs to teach CPR and participation in the CPR/AED Olympics [Not reported]			CC-V	+	Not reported	Not reported	-
Gabriel, 2019 [46]	A lecture, a discussion session, and practical training [Not reported]				CC-V	+	+	-	-
Yeung, 2017 [47]	F2 F group: introductory lecture and practical training with an instructor [Not reported]	Lifesaver group: introductory lecture and Lifesaver programme on a handheld tablet [Not reported]	Lifesaver and F2 F group: introductory lecture, Lifesaver programme on a handheld tablet, and practical training with instructor [Not reported]		CC-V	-	+	-	1:6
Zeleke, 2019 [48]	Control group: CPR instructional video [Not reported]	Music group: CPR instructional video and practical CCs in time with a popular song [Not reported]	Video game group: CPR instructional video and learning how to time CCs with a video game [Not reported]		CC	-	+	-	-
Suss-Havemann, 2020 [49]	Intervention group: interactive lecture and practical training. The students guided their own learning, and the trainer supervised. Students were split into small groups and took turns as one explainer, two performers and one evaluator. [90]	Control group: interactive lecture and practical training with a four-step approach (demonstration, deconstruction, comprehension, and execution of the learning) [90]			CC	+	+	Training cards	2:16–24
Schmid, 2018 [50]	Theory-based video, review of BLS steps, and practical training [29]				CC	-	+	-	-

AED Automated external defibrillator, BLS Basic life support, CC Chest compression, CC-V Chest compression and ventilation, CO-CPR Chest compression only cardiopulmonary resuscitation, CPR Cardiopulmonary resuscitation, QCPR Quality of cardiopulmonary resuscitation, F2 F Face-to-face

^a instructor:pupil ratio

Evaluation methods

Of the studies that evaluated CC, almost half assessed CC alone (n = 14) and half assessed CC-V (n = 13) (Table 3). Almost three quarters of the CC assessments focused on depth (n = 19), and almost all evaluated the rate (n = 24). Evaluation methods were based on a questionnaire-based test of theory (n = 20), practical skills (n = 13), or a scenario-based exercise (n = 11). Some studies evaluated participants in a competitive environment (n = 2). The evaluation time points varied greatly. Almost three quarters of the studies performed a baseline evaluation (n = 21), most performed a post-training evaluation (n = 27), and more than half performed a follow-up evaluation (n = 15). Post-training evaluations were conducted immediately after the training in 18 studies, 1 week after in 7 studies, and up to 2 months later in 2 studies. The follow-up evaluations were conducted from 2 weeks to 6 years after the training.

Table 3.

Evaluation methods

Study	Evaluation method	Variables evaluated			Evaluation time points [time after training]
		BLS sequence	CPR	AED use	Baseline evaluation	Post-training evaluation	Follow-up evaluation
Tanaka, 2020 [23]	Psychomotor and cognitive tests	+	CC [depth/rate]	+	K-test	QCPR	K-test [2 wk]
Martínez-Isasi, 2021 [24]	2-min CPR simulation scenario	+	CC-V [depth/rate]	+	-	QCPR	QCPR [4 months]
Abelairas-Gomez, 2021 [25]	Simulated OHCA scenario	+	CC [depth/rate]	-	-	Checklist and QCPR [1 wk]	Checklist and QCPR [2 yr]
Beck, 2015 [26]	5-min objective, structured clinical examination	+	CC [depth/rate]	-	-	Checklist	-
Monteiro, 2021 [27]	Questionnaire (10 items on the theory, 4 items on efficacy)	+	CC	-	K-test and attitude	K-test and attitude [1 d-1 wk]	K-test and attitude [6 months]
Tony, 2020 [28]	Questionnaire	+	CC-V [rate]	-	K-test	K-test	-
Aguila, 2019 [29]	Questionnaire, practical skills on a manikin, and attitude assessment	+	CC-V [rate]	-	K-test and attitude	QCPR [im], K-test and attitude [1 wk]	K-test and attitude [6 months]
Kua, 2018 [30]	Questionnaire and attitude assessment	+	CC [depth/rate]	+	K-test and attitude	K-test and attitude	-
Li, 2018 [31]	Questionnaire, practical skills on a manikin, and attitude assessment	+	CC-V [depth/rate]	-	K-test and attitude	K-test and QCPR	-
Ballesteros, 2020 [32]	Questionnaire	+	CC-V [rate]	-	K-test	K-test	K-test (only practical group) [2 months]
Lukas, 2016 [33]	Questionnaire, self-efficacy, and practical assessment	+	CC-V [depth/rate]	-	K-test, QCPR and attitude	-	K-test and QCPR [1, 3 and 6 yr] and attitude [3 and 6 yr]
Nord, 2016 [34]	Practical skills	+	CC-V [depth/rate]	-	-	QCPR	QCPR [6 months]
Onan, 2019 [35]	Questionnaire, observable BLS checklist, BLS skill measurement, and attitude assessment	+	CC-V [depth/rate]	-	K-test and attitude	K-test, checklist, QCPR and attitude [1 wk]	-
Otero-Agra, 2019 [36]	Practical 2-min CPR quality test	-	CC [depth/rate]	-	-	QCPR [1 wk]	-
Kitamura, 2016 [37]	Questionnaire and attitude assessment	-	CC	+	Attitude	K-test	-
Kesici, 2021 [38]	Questionnaire, BLS checklist, and attitude assessment	+	CC-V [depth/rate]	+	K-test, checklist and attitude	K-test, checklist and attitude	-
Pivac, 2021 [39]	Questionnaire	+	CC	+	K-test	K-test	-
Wingen, 2018 [40]	Questionnaire and attitude assessment	+	CC-V [depth/rate]	-	K-test and attitude	K-test and attitude	K-test and attitude [6 months]
Semeraro, 2017 [41]	Questionnaire and 2-min QCPR test	-	CC [depth/rate]	-	K-test and QCPR	QCPR [2 months]	K-test and QCPR [5 months]
So, 2020 [42]	Questionnaire, scenario-based test, and attitude assessment	+	CC [depth/rate]	+	K-test and attitude	Checklist	K-test, checklist and attitude [3 months]
Tsai, 2019 [43]	Questionnaire and attitude assessment	+	CC [rate]	-	K-test	K-test [1 wk]	-
Varela-Casal, 2021 [44]	BLS simulation scenario	+	-	-	Checklist	Checklist [1 wk]	Checklist [1 month]
Vetter, 2016 [45]	Questionnaire, scenario-based psychomotor test, and attitude assessment. For the study group: scenario-based assessment at follow-up	+	CC-V [depth/rate]	+	K-test, checklist, QCPR and attitude	K-test, checklist, QCPR and attitude [2 months]	Checklist and QCPR [12 months]
Gabriel, 2019 [46]	Questionnaire and BLS checklist	+	CC-V [depth/rate]	+	K-test	K-test and checklist [4 d]	-
Yeung, 2017 [47]	Questionnaire, attitude assessment, and BLS checklist	+	CC-V [depth/rate]	-	K-test and attitude	Checklist, QCPR and attitude	Checklist and QCPR [3 months and 6 months]
Zeleke, 2019 [48]	Emergency (911) call and CC checklist	-	CC [rate]	-	-	Checklist	-
Suss-Havemann, 2020 [49]	3-min scenario checklist and attitude assessment	+	CC [depth/rate]	+	-	Checklist, QCPR and attitude	Checklist, QCPR and attitude [9 months]
Schmid, 2018 [50]	Questionnaire	+	CC [depth/rate]	-	K-test	K-test	-

AED Automated external defibrillator, BLS Basic life support, CC Chest compression, CC-V Chest compression and ventilation, im immediately, K-test Knowledge test, OHCA Out-of-hospital cardiac arrest, QCPR Quality of cardiopulmonary resuscitation, wk Week, yr year

Effectiveness of training: skill acquisition and retention

Firstly, only 1 study focused on the influence of age; the greatest improvement in knowledge was observed in the youngest group (mean age: 12.5) (Table 4). Four studies had focused on hands-on practice =. Three of these four studies compared theory-based training alone with theory- and practice-based training. All found a greater improvement in BLS knowledge in the theory- and practice-based group. Another study did not include a control group but also found an improvement in knowledge with hands-on practice. Five studies assessed the influence of the training material. One study compared DVD-based training with smartphone-application-based training. They reported that DVD-based training appeared to be better in terms of practical skills. In contrast, another study found that the use of feedback devices increased CPR knowledge and practical skills. Immersive VR training has also be shown to be effective in terms of skill acquisition. Lastly, 2 studies evaluated the use of stuffed animals, cuddly toys or learning tools when training young children; both found that the use of learning tools is associated with greater knowledge acquisition and retention.

Table 4.

Effectiveness of training: findings concerning skills (acquisition and retention) and attitudes

Study	Findings concerning skills		Findings concerning attitudes
	Post-training	Retention
Tanaka, 2020 [23]	The two groups showed similar improvements in CPR skills, suggesting that school teachers who have never taught CPR can provide the same quality of psychomotor skills and cognitive knowledge through CPR trainingas those with CPR teaching experience, using PWW-based QCPR-Classroom-enhance training	At 2 weeks, there was a significant improvement in BLS knowledge over baseline in both groups but no difference between the groups
Martínez-Isasi, 2021 [24]	The type of training in cycles of 1 or 2 min does not show any real improvement in CPR quality after immediate training	After 4 months, the type of training in cycles of 1 min or 2 min was not associated with a real improvement in CPR quality. However, skills on sequence performance dramatically declined, and only 40% remembered to alert the EMS. This led the researchers to conclude that that re-training and/or re-assessment should be performed in periods shorter than the 4 months originally intended
Abelairas-Gomez, 2021 [25]		In 8-to-12-year-old schoolchildren, although annual 50 min retraining sessions help to maintain BLS performance (Standard group), 4-month very brief rolling-refreshers were shown to be even more effective (Rolling-refresher group)
Beck, 2015 [26]	Although this study failed to demonstrate the non-inferiority of peer-led training compared with professional-led training, they support the effectiveness of peers as instructors for students. Using peers as instructors holds the potential to develop a comprehensive and sustainable educational concept for BLS-training in schools
Monteiro, 2021 [27]		A single 120-min BLS training session provided by medical students to schoolchildren is effective in promoting the acquisition of theoretical knowledge with results lasting for over a 6-month period	Self-confidence in the ability to perform CPR lasted for 6 months after the initial training
Tony, 2020 [28]	Results demonstrated the effectiveness of the intervention with the expansion of the knowledge acquired through the comparison between the pre and post-test
Aguila, 2019 [29]	Training by a schoolteacher was effective for immediate knowledge and skill acquisition	After 6 months, a decrease in knowledge was observed but an increase in attitudinal skills was noted	The proportion of trainees who were confident in their ability to perform CPR increased from 37% before training to 50% after training
Kua, 2018 [30]	Following a video-based CPR/AED training with hands-on practice, a pilot group of Singapore schoolchildren demonstrated CPR/AED knowledge acquisition		Before training, 40% of students were unlikely to use AED because of fear; this proportion fell to 12% after training. With regard to training methods, the students wanted to have “humorous videos” when learning about CPR and AED, both before and after training
Li, 2018 [31]	This study revealed that primary and secondary school children in China had little pretraining knowledge of CPR. However, with training, there was a significant improvement in the basic theory and skills of CPR		Before training, 73% of students were willing to share their knowledge with others
Ballesteros, 2020 [32]	Practical training gave better results than knowledge-based training	After 4 months, a decrease in knowledge was observed in the practical group
Lukas, 2016 [33]	General knowledge about CPR improved in all of the pupils after the theory lessons. There were no differences in the skills achieved between the groups with different instructors. Pupils who were trained by teachers performed better in the knowledge	The extent to which knowledge was retained after 6 years was very good. Even following a 3-year interval with no training, the pupils were still able to recall information about the theory involved in resuscitation	In the group with a 3-year pause, self-efficacy fell after 6 years
Nord, 2016 [34]	Overall, a 50 min DVD-based training seemed to be superior to a 30 min app-based education in terms of teaching practical CPR skills to seventh grade students. After CPR training, a majority of students, regardless of the training method, were willing to make a life-saving effort. However, only a third of the students would do both compressions and ventilations if a stranger suffered a cardiac arrest	In terms of long-term retention, practical CPR skills fell significantly 6 months after training in both groups. The DVD and app groups respectively obtained 58% and 53% of the maximum score
Onan, 2019 [35]	Comparing the instructions, the mobile-assisted program (group C) significantly increased the knowledge scores of the students. Theoretical BLS training did not result in mastery of basic psychomotor skills without hands-on practice. Self-instruction, guidance, and feedback by the smartphone app improved students’ compression quality		The result of this study confirmed that BLS training increases laypersons’ confidence. Results showed that Group C students expressed higher confidence in their ability to act in an emergency when they witnessed a victim collapsing
Otero-Agra, 2019 [36]	Students who trained using a team-based methodology did equally well or better on many parameters in the CPR test compared with three other methodologies where students worked as individuals. Gamification resulted in higher CPR quality than non-compulsory and non-tested methods of academic training with instructor or visual feedback
Kitamura, 2016 [37]	This study underscored that simplified systematic CPR training of chest compression and AED use encouraged elementary school children to better understand how to perform chest compression and use an AED		This study showing the change in attitudes after training, irrespective of age and school year, suggests that elementary school children can learn the general outline of CPR and AED use and have a positive attitude towards CPR
Kesici, 2021 [38]	Results of the pre-post training awareness questionnaire, pre-post training knowledge tests, and the practical exam indicated that instructors trained by their peers are as effective as the instructors trained by medical physicians in terms of giving BLS training to high school students		The pre-/post-training reduction in hesitation in applying BLS was greater in group B (6.4%) than in group A (1%)
Pivac, 2021 [39]	Post-training levels of theoretical CPR knowledge were higher in all groups. The greatest increase in knowledge was observed among seventh graders (mean age: 12.5 years)
Wingen, 2018 [40]	After intervention, CPR knowledge was significantly higher in the intervention than in the control group. Analysis showed that short-term increase of CPR knowledge in the intervention group was independent of any subgroup-specific characteristics	After 6 months, the level of knowledge in the intervention group was still high and significantly improved compared with the control group	Before CPR training, there was no difference in the self-reported level of self-confidence towards initiating CPR between the intervention and control group. Participation in CPR training resulted in a significant increase of self-confidence in the intervention group
Semeraro, 2017 [41]	A single time use of Relive the serious game RTM was able to improve significantly the quality of CC in a group of schoolchildren without any previous experience in CPR	Relive was also able to improve retention of CPR knowledge and skill after only one session of competition
So, 2020 [42]		A valuable and noticeable increase in knowledge score was associated with the course, with correct responses of more than 90% to each question observed after the 3-month follow-up. Students maintained a high level of BLS skills competency at follow-up	Students had a very positive attitude towards CPR, with no change in the mean attitude score over time
Tsai, 2019 [43]	The short CPR/AED education session significantly improved the knowledge of the adolescents		Although the adolescents reported a significant increase in their willingness to perform CPR after the training session (from 9.5% to 42.6%), the majority were still unwilling to do so
Varela-Casal, 2021 [44]	Using the Rescube and Endless Book resulted in higher correct percentages in the overall performance following the chain of survival steps with slightly better results with the Rescube as a learning tool	The use of Rescube or Endless Book resulted in greater retention. Compared with the Endless Book group, the Rescube group had a better retention rate for checking consciousness and breathing; however, there were no intergroup differences for the other items
Vetter, 2016 [45]	Cognitive knowledge improved significantly between pre-and post-testing in both the Control and Study Classes. Psychomotor skills improved between pre-and post-testing	Loss of cognitive knowledge was observed at retention testing in both Control and Study Classes with a significant loss only for the Study Class. There was a significant loss in retention of PM skills in the Control Class but not in the Study Class. Students who developed creative and novel methods of teaching and learning resuscitation skills showed outstanding application of these skills in a Mock Code	In both Control and Study Classes, willingness to perform CPR, either by mouth-to-mouth or hands-only improved significantly from pre- to post-testing
Gabriel, 2019 [46]	The main findings from this study were that most of the students lacked knowledge regarding BLS before training, and were found to have no skills exposure whatsoever concerning BLS at baseline, but after the training, they performed reasonably well in the “hands on skills”
Yeung, 2017 [47]	The post-training CPR score was better in the combined group. The CPR score was better in the F2 F-only group than in the lifesaver group	At 3 months and 6 months, the combined group had a better CPR score. There was no difference between the F2 F and lifesaver-only groups	The combined group showed better attitude outcomes. There was no difference between the F2 F and lifesaver-only groups in terms of attitude skills
Zeleke, 2019 [48]	Most children remembered to call 911 and performed CPR at the correct anatomic location. Most produced high-quality CCs. The music group and the video game group both attained the compression rate goal for effective CPR, whereas the performance in the control group was worse
Suss-Havemann, 2020 [49]	This study could not demonstrate that self-regulated learning is effective for CPR training in students	Self-regulated learning is only beneficial for male students. The males of the intervention scored higher than the males of the control because of better retention for breathing check, chest compression quality and less pauses	This study demonstrates that a high percentage of students had self-confidence to help effectively in cardiac arrest after the training and nine months later
Schmid, 2018 [50]	This study demonstrated the effectiveness of the “CPR Anytime” video and mannequin intervention among middle and high school children in the Grand Metropolitan Area of Costa Rica		After training, almost 73% of children reported they “would be comfortable” performing CPR

AED Aautomated external defibrillator, BLS Basic life support, CC Chest compression, CPR Cardiopulmonary resuscitation, EMS Emergency medical services, F2 F face-to-face, N/A Not applicable, QCPR Quality of cardiopulmonary resuscitation

Eight studies focused on the instructor’s role. Two studies compared instructor-led training with self-instruction: one found that instructor-led training was better and the other found that a combination of instructor-led training and self-training was better. Two other studies included training by peers. One showed that peers trained by other peers and peers trained by physicians were similarly effective, and the other indicated that instructor-led training resulted in better skill acquisition than peer-led training.Another (noncontrolled) study showed that the use of medical students as instructors enabled greater skill acquisition and yet another found the same for teachers. One study found that a medical/training background for the trainer is not associated with better skill acquisition. Lastly, a study found that having teachers as instructors increased knowledge acquisition (vs. healthcare professionals).

Five studies evaluated the impact of including videos in the training. Two noncontrolled studies included video in their theory-based training and found an increase in skill acquisition. Three other studies included video in the CPR practice demonstration. Only one had a comparator group. All three revealed significant skill acquisition, and two identified significant skill retention as well.

Four studies evaluated the duration of the training session or the inclusion of a refresher training session. A first one identified that self-efficacy decrease with long pause, a second one exposed that short training could offer a significant skill acquisition (without control group). A third study showed that a 1-min CC training cycle is similar to a 2-min CC training cycle in terms of skill acquisition and a fourth study found that a refresher session improved skill retention. Particularly, skill retention was better when the refresher session took place every 4 months, rather than every year.

Lastly, 5 studies included different methodologies. Three noncontrolled studies found that a conventional training session (including a lecture and practical training) was associated with an improvement in skill acquisition. Two other studies indicated that evaluating knowledge and practical skills in a competitive environment enabled better skill acquisition and skill retention.

Attitudinal findings

Fifteen studies assessed the attitudinal impact of training (Table 4) [25, 26, 29–34, 36–38, 42, 47–49]. Ten of the latter identified a significant increase in the ability and willingness of schoolchildren to perform CPR in a real-life situation [25, 26, 31–34, 36–38, 47]. One study also found that fear of using an AED decreases drastically (from 40% of the trainees to 12%) after training [49]. Another study showed that a long time interval without BLS training is linked with a significant decrease in self-confidence in performing BLS [29]. Four studies identified differences in willingness to perform CPR after training, depending on the training method used [32–34, 38]. Lastly, one study found that the population’s characteristics (age and school year) were not associated with changes in attitude [36].

Discussion

Our review of the literature published between 2015 and 2022 covered different methods of BLS training for schoolchildren and identified those that appear to be the most effective in terms of acquiring and retaining knowledge and skills. We did not find any studies in France on this issue or studies assessing the evaluation of information retention. In general, the training methods varied greatly from one study to another. This nevertheless showed that many approaches can (at least in the short term) improve schoolchildren’s CPR skills and knowledge. We found that the inclusion of a practical training session is essential for increasing BLS skill acquisition and retention in children. Moreover, refresher sessions were clearly important. Lastly, the assessment of schoolchildren’s BLS skills appears to be most effective when conducted in a competitive or challenging environment.

The methodologies

From a purely methodological point of view, our review identified similarities between the various training methods. Firstly, several studies found that the general framework usually used in adult training (i.e. formal knowledge transfer, demonstration of BLS, and then practice) is also applicable to child trainees [43, 45, 48]. The importance of practice is emphasized by some researchers [32, 39, 40]. However, other researchers also point out that the training framework and tools must be age-appropriate (e.g. with role-playing, simple methods, teamwork [36, 37], cuddly toys [41, 42], comics [41], and virtual reality [35]). Several studies also emphasized the usefulness and value of video tools in theory-based courses [30, 31] or practical demonstrations [27, 48, 49]. Lastly, several reviewed studies highlighted the value of shorter training sessions [25] (especially during CPR practice) suited to a child’s physical ability [50].

Training by whom and for whom?

Some of the studies were looked not only at the training but also at the trainer. Firstly, it was clear that training by a trainer is better than self-training [38, 47]. Subsequently, several studies showed that teacher trainers give very good results in terms of information acquisition and retention [26, 44]. Indeed, the results with teachers were sometimes better than when the trainer was a healthcare professional [29]. Two studies assessed the impact of the training by peers. The first showed that information acquisition and retention in peer training were no worse than when children were trained by expert instructors [23]. The second showed that peers trained by peers provided the same quality of training as peers trained by healthcare professionals [33]. In other words, these results highlighted the importance of the teaching method adopted by the trainer and his/her ability to adapt the method to the type of trainee. A recent study including articles between 1975 and 2022 showed that self-training is a good option especially when the use of new technologies is implemented [51].

The age of the schoolchildren trainees ranged from 5 to 18. The training courses generally targeted adolescents aged 13 or 14, although the researchers never gave a rationale for the selection of particular age groups. Only one study focused on the age of trainees, with three age groups (mean ages: 12.5, 13.5, and 14.5); information acquisition and retention was best in the youngest group [52]. However, we observed that most CPR training studies included older children: only 2 studies included children under the age of 10 [41, 42] and only one focused solely on that age class [41]. Unfortunately, none of the studies compared the outcomes as a function of age. However, all found that BLS training is effective in young children, with good acquisition and retention of knowledge and practical skills. These results reinforce the hypothesis whereby train very young children in BLS might be useful and effective.

Refresher training sessions

We noted that brief refresher sessions at regular intervals enabled trainees to maintain (at least to some extent) the knowledge and skills acquired during the initial training [24]. One study found that in the absence of refresher sessions, the effectiveness of CPR decreased [29]. If children are trained at a younger age, they will logically benefit from more refresher training sessions during their school career; this might consolidate their knowledge as they grow up.

Evaluation of training methods

We observed that the evaluation of training in a competitive environment gave better results than evaluation in a classroom environment [28]. Furthermore, we noted that almost half of the included studies assessed students'knowledge through a scenario or through role playing. Hence, we consider that the combination of a scenario-based assessment of the BLS sequence with a formal knowledge assessment is effective and appropriate.

Changes in attitude

Lastly, our review showed that along with the acquisition of knowledge and practical skills, some training methods also allowed schoolchildren to acquire self-confidence and increase their willingness to perform CPR in a real-life situation. These methods would be the use of new technology (virtual reality) or by learning through a serious game.

Limitations

This review had some limitations. First, none of the included studies measured the impact of different training methods on the population level. The level of detail given for the methods varied markedly. This left some studies open to some subjective interpretation, which might have induced bias. Lastly, the heterogeneity in the training and evaluation methods prevented us from direct comparisons. However, the major objective was to identify key elements that are useful for training schoolchildren in BLS, rather than to compare studies.

Conclusions

The results of our literature review showed that BLS training methods and tools can be effective in children. In particular, we found that the conventional pattern of training used in adults (theory, demonstration, and practice) is applicable to children – as long as all the steps are adjusted for the younger audience (the material, the trainer, and the duration of the training session). We also observed that refresher training is essential for maintaining and reinforcing the BLS knowledge and skills acquired by schoolchildren.

The European Resuscitation Council’s Kids Save Lives project recommends training not only adolescents but also younger schoolchildren in BLS. Few studies have focused on this very young population, even though some studies suggest that it is possible. In France, the next step would be to (i) implement a study of training in young schoolchildren, (ii) evaluate the impact of specific, formal, theory-based and practical training on the acquisition and retention of information at various time points, and (iii) assess the need for refresher training sessions. This next step will be the ELSA study, “evaluation of life saving training”. The final aim of this study is to offer a training program.

Abbreviations

AED

Automated external defibrillator

BLS

Basic life support

CC

Chest compression

CC-V

Chest compression and ventilation

CPR

Cardiopulmonary resuscitation

CO-CPR

Chest compression only cardiopulmonary resuscitation

EMS

Emergency medical services

F2 F

Face-to-face

MICU

Mobile intensive care unit

OHCA

Out-of-hospital cardiac arrest

PICO

Population, intervention, comparison and outcomes

PRISMA

Preferred Reporting Items for Systematic Review and Meta-Analyses

Q-CPR

Quality of cardiopulmonary resuscitation

Authors’ contributions

VB and HB wrote the main manuscript text. V.B., M.R. and H.B. made substantial contributions to study conceptualization, design of the survey, acquisition, analysis, and interpretation of data, and contributed to drafting and reviewing the work. M.R., and H.H. contributed to the acquisition, analysis, and interpretation of data contributed substantially to the original draft and substantively revised it. M. L, G.H. et C.V. revised manuscript content. All authors read and approved the final manuscript.

Funding

Nothing to declare.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study and the French national cardiac arrest registry RéAC were approved by the French Advisory Committee on Information Processing in Health Research (CCTIRS (Paris, France)) on 10/14/2010 (number 10.326 Ter) and the French National Data Protection Commission (Commission nationale de l’informatique et des liberte´s (Paris, France): authorization number: 910946) on 04/06/2012.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.