Bridging the emergency response gap: evaluating CPR knowledge and preparedness among healthcare students at the University of Kalamoon

Abstract

Background

Cardiac arrest is a leading cause of sudden death worldwide, and prompt cardiopulmonary resuscitation (CPR) significantly increases survival rates. Assessing the knowledge and awareness of CPR among healthcare students is essential, as they represent future frontline responders in emergency situations.

Methods

We conducted a cross-sectional study at the University of Kalamoon in Syria, where the survey included 600 students from three medical faculties using a voluntary electronic and paper questionnaire. The questionnaire combined self-efficacy regarding performing CPR and scientific knowledge according to the latest protocols, as well as assessing and studying the most important concerns that prevent students from performing chest compressions for both friends and strangers. SPSS software was used to analyze the data using ANOVA tests and independent t-test, in addition to descriptive analyses.

Results

The majority of the sample were females (72.8%), and more than half of the participants had not received any prior training on the principles of basic life support (54.2%). Both the academic major and the academic year showed statistically significant differences, where higher levels were observed among students of the Faculty of Human Medicine and sixth-year students (P-value < 0.001), while gender did not show any statistically significant differences (p-value = 0.058). 17.2% of the sample strongly agreed to perform chest compressions for a person who needs them. The two most important reasons preventing students from performing chest compressions on a stranger were making a mistake and legal punishment.

Conclusion

Integrating CPR courses as a graduation requirement in medical schools in Syria, along with the need to organize interactive workshops and issue certificates as a means of motivating students, are essential means of promoting CPR concepts scientifically and theoretically, given its importance due to the numerous conflicts and wars in recent times.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12245-026-01304-z.

Background

Cardiopulmonary resuscitation (CPR) techniques have undergone a revolution in development and modernization since their inception in the fifteenth century. They began with primitive devices and methods, such as the Bellows method of blowing air into a patient’s mouth. Then, in 1740, the Paris Academy of Sciences commended the importance of mouth-to-mouth resuscitation and its usefulness for drowning victims, a technique still used today. Developments and modifications have not been limited to devices and techniques, but have also extended to the duration and depth of compressions [1]. The inability or failure of the heart to pump blood effectively as in its normal condition leads to the cessation of blood flow and consequently the occurrence of cardiac arrest, which is considered a life-threatening medical emergency that requires rapid intervention [2]. Each of the absence of a palpable pulse, loss of consciousness, and abnormal breathing patterns is considered important clinical evidence of cardiac arrest [3]. Annually, an estimated 95.5 cases of adult sudden cardiac arrest occur per 100,000 people [4]. The American Heart Association (AHA) considers CPR to be an essential component of the “chain of survival”, as most studies urge the necessity of performing CPR quickly and correctly because this would increase the chances of survival, remaining alive, and double them in patients with cardiac arrest [5]. Out-of-hospital sudden cardiac arrest (OHCA) is responsible for over 60% of all cardiovascular disease-related deaths, making it an important cause of mortality globally [6]. In Europe alone, OHCA is the cause of 350,000 people losing their lives [7]. Given the great importance of bystander CPR, the world health organization (WHO) recommends that CPR training be incorporated into secondary school curricula as a core component of basic life support (BLS) education [2]. The years of war in Syria, which have lasted for more than a decade, have weakened the infrastructure of various sectors, particularly the health and education sectors. This has negatively impacted the quality of services provided by medical colleges and the academic performance and learning outcomes of their students [8, 9]. Consequently, it has become commonplace for emergency services to be limited, with a marked disparity in the quality of healthcare both within and outside hospitals. Therefore, this study aims to assess the level of knowledge, confidence, and fears of healthcare students regarding CPR, in order to guide and develop educational strategies in the context of a conflict-affected country like Syria, and thus contribute to improving the chain of survival and raising the level of resuscitation readiness within the Syrian health system.

Methods

Study design

There are three medical faculties at the University of Kalamoon (UOK) in Syria (Human Medicine; Dentistry; Pharmacy); we targeted students of these three faculties through a cross-sectional study using two methods: the first by using an electronic questionnaire that we published on students’ social media platforms such as WhatsApp and Telegram, and the second by using a paper questionnaire that we distributed in places where students gather such as the cafeteria, the university campus, the library, and the sports field. Our team carried out the data collection task over a period of approximately one month, from March 12 to April 12, 2025, and this period was chosen with the aim of allowing sufficient time to reach students from different colleges and academic years, in addition to taking into account the differences in their academic schedules and examination periods, and thus ensuring broad and representative participation.

Sample size

The minimum required sample size, calculated using Cochran’s formula at a 95% confidence level and a 5% margin of error, was 336 participants. To improve statistical power, increase estimate precision, and ensure adequate representation across the three colleges, the planned sample size was increased beyond the minimum requirement.

Participants and data collection

Convenience sampling was used to select participants. A total of 730 male and female students were approached to participate in the study. Of these, 600 students completed the questionnaire and were included in the final analysis, resulting in a response rate of approximately 82.2%. We formed a research team consisting of 6 individuals trained in data collection methodologies to conduct face-to-face interviews with students during the process of distributing the paper questionnaire. Each interview took an average of 10 min per participant. We also made sure to explain the purpose of the study and its importance, and to clarify any details related to the study, especially for first-year students who found some difficulty in understanding some of the items. The exclusion criteria in our study included two main points: (1) Students who refused to complete the study or withdrew from it. (2) Incomplete responses. The study relied on a custom-designed cognitive assessment tool based on the latest guidelines from the American Heart Association, with necessary modifications to suit the local context.

Study tool (questionnaire)

The questionnaire was designed after a comprehensive review of international AHA guidelines and previously used tools in related studies [10–12]. The questionnaire underwent multiple stages of evaluation and peer review, with revisions by an emergency medicine specialist and the dean of the Faculty of Medicine to ensure clarity and scientific validity. The Arabic translation was meticulously reviewed by the first author and a team of specialists to guarantee linguistic and conceptual accuracy.

The questionnaire consisted of four main sections:

1. Demographic Data: Included gender, academic year, college, grade point average (GPA), financial status, and history of BLS training.

2. Self-Efficacy Toward First Aid and CPR: Comprised 6 items measuring the student’s self-efficacy in performing basic CPR procedures, using a 5-point Likert scale (from “Strongly Agree” to “Strongly Disagree”).

3. Concerns and Considerations Before Performing CPR: Included 2 questions assessing psychological or practical barriers that might influence a student’s decision to intervene in emergencies.

4. Knowledge Test: Consisted of 23 multiple-choice questions evaluating fundamental knowledge of CPR. Furthermore, each correct answer was worth one point, and the remaining options were worth zero points.

Pilot study and reliability

We conducted a pilot study with 28 students to assess the clarity and effectiveness of the questionnaire. We made very minor adjustments based on student feedback and then excluded them from the final analysis. We assessed the internal consistency of the self-efficacy scale (6 Likert-type items), resulting in a Cronbach’s alpha coefficient of 0.8, indicating high reliability. The fear items and knowledge questions were not subjected to internal consistency testing because they do not represent single latent constructs.

Ethical considerations

Participation was voluntary and without academic consequences. This study respected the participants through social media by including a question at the beginning of the electronic version asking for their consent to participate. Their agreement was considered as written informed consent. As for participants who completed the paper-based questionnaire, written consent was obtained from them. Ethical approval was obtained from the Institutional Review Board (IRB) at the Faculty of Medicine, University of Kalamoon, Syria.

Statistical analysis

Data were collected and manually checked to avoid errors before being entered into the Statistical Package for the Social Sciences (SPSS) version 22. Assumptions for parametric tests were examined prior to analysis. Normality was assessed using the Shapiro–Wilk test. Given the large sample size, parametric tests were considered sufficiently robust to minor deviations from normality. The analyses were primarily univariate (ANOVA and t‑tests). In addition, we used linear regression analysis to predict the factors that influence total knowledge in CPR. A significance level of p < 0.05 was considered statistically significant.

Results

Demographic characteristics of participants

A total of 600 undergraduate students were surveyed. The majority were females (72.8%). Exactly half of the sample came from middle-income families (50.0%), while only (8.5%) were from low-income families. The sample was selected from different faculties, with the highest proportion from the Faculty of Human Medicine (51.3%), followed by Pharmacy (31.2%) and Dentistry (17.5%). We also sought to include students from all academic years to ensure representation of a wide segment of students; the fifth year was the most represented (24.7%), followed by the third year (23.8%). Regarding academic GPA, only (4.5%) of the sample had a high GPA ranging from 3.5 to 4, while (44.7%) of the students had a GPA ranging from 2.5 to 2.99. Finally, 54.2% of students had not received any prior training regarding basic life support principles, see Table 1.

Table 1.

Demographic characteristics of the study sample

Category	Subcategory	N (%)
Gender	Female	437 (72.8%)
	Male	163 (27.2%)
Income Level	Low	51 (8.5%)
	Medium	300 (50.0%)
	High	249 (41.5%)
Academic Major	Medicine	308 (51.3%)
	Dentistry	105 (17.5%)
	Pharmacy	187 (31.2%)
Academic Year	First year	68 (11.3%)
	Second year	78 (13.0%)
	Third year	143 (23.8%)
	Fourth year	110 (18.3%)
	Fifth year	148 (24.7%)
	Sixth year	53 (8.8%)
GPA	3.5–4.0	27 (4.5%)
	3.0–3.49	147 (24.5%)
	2.5–2.99	268 (44.7%)
	2.0–2.49	148 (24.7%)
	< 2.0	10 (1.7%)
Received training in basic life support?	Yes	275 (45.8%)
	No	325 (54.2%)

Factors associated with CPR knowledge

In (Table 2), our results indicated that males were somewhat more knowledgeable than females regarding CPR; however, the difference was not statistically significant (p = 0.058). As for the university major, students of the Faculty of Human Medicine were the most knowledgeable compared to the rest of the medical faculties (p < 0.001). We also observed a noticeable improvement in the level of knowledge with the advancement of academic years, where the peak of knowledge was reached among sixth-year students, and the difference was statistically significant (p < 0.001). In contrast, GPA did not show any statistically significant associations with the level of knowledge (p = 0.080). Notably, the group of students with high income were more knowledgeable than students from the other income levels, especially the low-income group (p = 0.005).

Table 2.

Comparison of total knowledge score across demographic variables

Variable	Group	Mean ± SD	Statistical test	p-value
Gender	Female	8.87 ± 3.05	Independent t-test	0.058
	Male	9.42 ± 3.35
Academic Major	Medicine	10.07 ± 3.32	ANOVA (F = 42.7)	< 0.001
	Dentistry	7.39 ± 2.21
	Pharmacy	8.21 ± 2.62
Academic Year	First	7.31 ± 2.37	ANOVA (F = 20.8)	< 0.001
	Second	7.92 ± 2.39
	Third	7.94 ± 2.35
	Fourth	10.33 ± 3.61
	Fifth	9.97 ± 3.14
	Sixth	10.38 ± 3.28
GPA	3.5–4.0	8.07 ± 2.50	ANOVA (F = 2.09)	0.080
	3.0–3.49	8.81 ± 3.52
	2.5–2.99	9.40 ± 3.04
	2.0–2.49	8.76 ± 3.02
	< 2.0	8.40 ± 2.46
Income Level	Low	8.00 ± 2.62	ANOVA (F = 5.43)	0.005
	Medium	8.85 ± 3.16
	High	9.44 ± 3.16

Self-efficacy levels regarding CPR and first-aid skills

Our students showed moderate to high levels of confidence in most items. For example, 59.8% of them agreed to perform chest compressions for a person who needs them (mean 3.82 ± 0.88). On the other hand, 20.8% of the sample refused to use an automated external defibrillator (AED), and only 52 students strongly agreed to use it, while 28.0% chose the neutral option. Furthermore, confidence in performing mouth-to-mouth breathing was moderate, as only 42.0% agreed or strongly agreed, while 25.8% expressed disagreement (mean 3.16 ± 1.06). For more details, see Table 3.

Table 3.

Distribution of self-efficacy responses among participants regarding CPR and first-aid skills

Item	I strongly disagree n(%)	I disagree n(%)	Neutral n(%)	I agree n(%)	I strongly agree n(%)	Mean ± SD
1) I feel confident in my ability to recognize a person experiencing sudden cardiac arrest.	25 (4.2%)	89 (14.8%)	167 (27.8%)	282 (47.0%)	37 (6.2%)	3.36 ± 0.95
2) I would perform chest compressions to someone in need of them.	16 (2.7%)	39 (6.5%)	83 (13.8%)	359 (59.8%)	103 (17.2%)	3.82 ± 0.88
3) I would perform mouth-to-mouth breathing for someone in need of it.	48 (8.0%)	107 (17.8%)	193 (32.2%)	207 (34.5%)	45 (7.5%)	3.16 ± 1.06
4) If available, I would use an automated external defibrillator (AED).	50 (8.3%)	125 (20.8%)	168 (28.0%)	205 (34.2%)	52 (8.7%)	3.14 ± 1.10
5) I feel confident in my ability to provide first aid to a person experiencing a traumatic event.	19 (3.2%)	84 (14.0%)	141 (23.5%)	284 (47.3%)	72 (12.0%)	3.51 ± 0.98
6) I feel confident in my ability to respond quickly and effectively to someone injured during a traumatic event.	20 (3.3%)	57 (9.5%)	106 (17.7%)	325 (54.2%)	92 (15.3%)	3.69 ± 0.96

Multivariable linear regression analysis of knowledge predictors

After adjusting all variables, we found that academic major, income level, and academic year represent important predictors of knowledge. Students from the College of Dentistry and the College of Pharmacy recorded significantly lower knowledge scores compared to students from the College of Human Medicine (B = − 2.283, p < 0.001 and B = − 1.516, p < 0.001, respectively), while progression in academic year was associated with a statistically significant increase in knowledge (B = 0.552, p < 0.001). Moreover, income level was positively associated with knowledge (B = 0.402, p = 0.032). Another important result that also appeared in our findings is self-efficacy, which was a significant positive predictor, where each one-point increase in the self-efficacy score was associated with an increase of 0.099 points in knowledge (p = 0.001). In contrast, the variables of gender and GPA were not statistically significant predictors in the adjusted model (p > 0.05) (see Table 4).

Table 4.

Multivariable linear regression model predicting total knowledge score among participants

Predictor	B	SE	β	t	p-value	95% CI
Gender (Male vs. Female)	–0.154	0.267	–0.022	–0.575	0.565	–0.68 to 0.37
Income Level	0.402	0.187	0.080	2.153	0.032	0.03 to 0.77
Academic Year	0.552	0.080	0.261	6.896	< 0.001	0.39 to 0.71
GPA	0.014	0.137	0.004	0.102	0.918	–0.26 to 0.29
Self-efficacy Total Score	0.099	0.029	0.127	3.398	0.001	0.04 to 0.16
Academic Major (Dentistry vs. Medicine*)	–2.283	0.321	–0.276	–7.107	< 0.001	–2.91 to − 1.66
Academic Major (Pharmacy vs. Medicine*)	–1.516	0.272	–0.224	–5.565	< 0.001	–2.05 to − 0.98

*Medicine was used as the reference category for academic major

Primary barriers to performing chest compressions on relatives, friends, and strangers

Finally, when we asked the students about the most important reason that prevents them from doing chest compressions on relatives or friends, the option “fear of making a mistake” got the highest percentage while the second most important reason was “causing harm to body organs” and the third was “causing bone fractures” while only 4 students (0.7%) chose the reason “exposure to blood or vomit”. As for strangers the most important reason was also “making a mistake” while the second most common reason was “fear of legal punishment”. For more details, see Tables 5 and 6.

Table 5.

Primary concern preventing participants from performing chest compressions on friends or relatives

Main Concern	N	%
Making a mistake	371	61.8%
Causing bone fractures	54	9.0%
Causing internal organ injury	60	10.0%
Causing cardiac arrest	45	7.5%
Legal consequences due to patient harm	41	6.8%
Exposure to blood or vomit	4	0.7%
Risk of infectious disease	13	2.2%
Physical contact with the opposite sex	12	2.0%
Total	600	100%

Table 6.

Primary concern preventing participants from performing chest compressions on a stranger

Main Concern	N	%
Making a mistake	327	54.5%
Causing bone fractures	37	6.2%
Causing internal organ injury	60	10.0%
Causing cardiac arrest	37	6.2%
Legal consequences due to patient harm	72	12.0%
Exposure to blood or vomit	9	1.5%
Risk of infectious disease	29	4.8%
Physical contact with the opposite sex	29	4.8%
Total	600	100%

Discussion

Cardiac arrest and similar emergencies that also lead to loss of consciousness are alarmingly common [13]. That’s why learning how to perform CPR has become a vital skill; it can mean the difference between life and death when someone collapses outside a hospital setting. In fact, CPR training has been a recommended standard for healthcare professionals ever since official guidelines were first introduced more than four decades ago [14]. This study aimed to assess the level of knowledge regarding the basics of CPR among medical, dental, and pharmacy students at the University of Kalamoon, given their direct responsibility for providing emergency care and the focus of their education on rapid response to life-threatening situations [15]. The study did not reveal any statistically significant difference between males and females regarding knowledge of CPR, which is consistent with the results of the study by Hasnain et al. [16]. Comparatively, a study in Saudi Arabia showed higher levels of awareness and knowledge among males compared to females [17]. These variations might indicate that other factors are involved, and that gender itself does not have a consistent effect that can be generalized. The analysis revealed that medical students had higher levels of knowledge, possibly due to the increased number of practical training hours and early clinical exposure compared to dental or pharmacy students. A study conducted in Iran among medical sciences students showed that only 7% knew the correct compression depth during pediatric CPR [18]. In contrast, pharmacy students scored higher levels of proficiency in another study [19]. Students’ overall knowledge of CPR also increased as they progressed through their academic years. This is consistent with a study that included undergraduate students from Jordan, Syria, and Iraq [20]. Additionally, a previous study conducted among nurses in a Spanish hospital showed that 50% had not received CPR training for more than two years, and 93% of nurses considered that training should be maintained regularly [21]. In a study of 1,261 health professions students at a Saudi university, only 590 (46.8%) of them had taken a BLS course [22]. Interestingly, in our study, the numbers were largely consistent with the findings of that study: 275 students (45.8%) received CPR training, compared to 325 students (54.2%) who did not. In their study, Chen et al. found that nearly half of individuals who had received prior training in CPR basics and skills were only familiar with the procedure theoretically but felt unable to actually perform it when needed [23]. This highlights a broader problem: providing students with theoretical knowledge of CPR is not enough. It is essential to actively encourage them to internalize, master, and apply these life-saving techniques in their daily lives and in their future clinical roles. In short, it is not just about teaching CPR to any group in society, but also training them on how to perform it effectively. Adewale et al. found that despite the widespread use of social media among university students, it was not nearly as effective as lectures in raising CPR awareness [2]. While the top three sources of CPR learning in a study conducted by Alsharari et al. in Saudi Arabian universities were university, the internet, and reading, social media ranked fifth [6]. Based on the above, we call for universities to focus on emergency preparedness curricula and adopt advanced practical models to enhance students’ skills as a crucial and primary source of learning during youth. According to the results of our study, the fear of making a mistake was the most common reason that prevented participants from performing CPR, whether on relatives or strangers, followed by fears of causing internal injuries or facing legal consequences. Supporting this finding, a study conducted in Taiwan found that fear of legal consequences was the most common reason participants refrained from performing CPR, followed by fear of causing harm to victims [24]. In this context, another study found that women are less likely to receive CPR due to fears of legal liability related to accusations of sexual harassment [25]. In the United Arab Emirates, reluctance to perform CPR on strangers was largely influenced by cultural and religious norms [26]. Furthermore, some participants in our sample reported concerns about exposure to blood or vomit, which may be attributed to their learning of mouth-to-mouth resuscitation techniques [27]. On the other hand, our students’ level of self-efficacy was significantly higher in basic procedures such as chest compressions and rapid response in traumatic events, while it was lower with regard to the use of AED or mouth-to-mouth resuscitation, indicating a competency gap in procedures that require either technical skills or direct contact. Income level was observed to be positively related with knowledge of CPR; this could be explained in the context of lifestyle and the expenses of courses and training programs. A study found that entrepreneurs were the most aware of cardiac arrest [28]. This underscores the need for free, accessible programs such as the WHO initiative in Uganda, which could play a vital role in narrowing the knowledge gap [29]. Cumulative GPA did not show a statistically significant association with knowledge of cardiopulmonary resuscitation in our study, nor was GPA a factor in willingness to perform CPR in Alshamrani’s study [30].

Conclusions

Our findings highlight the importance of integrating CPR courses as a graduation requirement for medical colleges in Syria, in addition to the need for interactive workshops and the issuance of certificates as a means of motivating students. Moreover, strengthening the role of universities and public health centres as reliable and sustainable sources for CPR training is of great significance. Further research is needed on the disparities in knowledge and self-efficacy toward CPR among medical, dental, and pharmacy students, especially given that all of them are expected to have sufficient knowledge and share, in one way or another, responsibility for saving human lives.

Limitations

Despite the exciting and important results presented in this research, which was conducted at one of the most important and largest universities in Syria, we acknowledge a number of limitations. The most prominent of these is that the research was conducted at one university and within a specific geographical and educational context, and therefore the results may not be generalizable. In addition, the questionnaire used in the study measured the cardiopulmonary resuscitation skills of healthcare students from a theoretical perspective and did not include any practical applications, and therefore lacks objective evaluation. Finally, the use of convenience sampling and self-reported data may have introduced selection and response bias.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CPR

Cardiopulmonary resuscitation

SCD

Sudden cardiac death

AHA

American Heart Association

OHCA

Out-of-hospital sudden cardiac arrest

WHO

World Health Organization

BLS

Basic Life Support

Author contributions

All authors have participated in writing the manuscript and reviewed the literature. Dr. Hamdah Hanifa and Dr. Mohammad Fayyad conceived and supervised the conduct of the study. All authors read and approved the final manuscript.

Funding

There are no sources of funding to declare.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to privacy and ethical considerations but are available from the corresponding author on reasonable request.

Declarations

Human ethics and consent to participate

The study adhered to the principles of the Declaration of Helsinki. Ethical approval for this study was obtained from the Institutional Review Board (IRB) at the University of Kalamoon (ID Number: 48/EBR-UOK, 2024). All participants provided informed consent. The data were maintained confidential throughout data collection and analysis.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.