Availability and Quality of Internet-Based Cardiopulmonary Resuscitation Training Films Featuring Women Experiencing Cardiac Arrest

Abstract

This study examines videos of cardiopulmonary resuscitation on Google and YouTube to discern the number that show women or female manikins and provide information to facilitate attempts to rescue women in cardiac arrest.

Despite efforts to reduce disparities in cardiopulmonary resuscitation (CPR) provision, men are more likely than women to receive bystander CPR worldwide.^1,2 Women have worse outcomes following out-of-hospital cardiac arrest than men.^1,2,3 In the Resuscitation Outcomes Consortium registry, men had a 29% increased probability of survival to discharge compared with women.¹

Bystanders report common themes behind hesitation to perform CPR on women. Bystanders are less likely to remove clothing and place hands properly because of fears of personal violation, breasts interfering with CPR, and causing physical injury.^4,5

Methods

The study was a cross-sectional analysis performed using the most common online search engine (Google) and the most common online video site (YouTube) to identify free, online instructional CPR films. Institutional review board approval and consent procedures were not required because this was not human subjects research. Each site was queried by searching for the phrase “how to do CPR.” The search was restricted to page 38 of the search results for Google (374 videos) and page 25 of the search results for YouTube (500 videos). Exclusion criteria included humor/parody or noninstructional content, pediatric CPR, CPR on animals, non–English language content, live videos, content from an in-hospital location, duplicate videos, CPR on a pregnant woman, or CPR on a man. The affected person’s sex was assessed visually by the authors. Although the face of Resusci-Anne, a CPR manikin, is modeled after a young woman, the torso lacks breasts and the manikin is considered unisex. Therefore, videos with no person in cardiac arrest other than this manikin were not considered to feature a woman experiencing cardiac arrest, particularly given that breasts are a common barrier to performing CPR on a woman.

Videos were scored (C.W.L.) and reviewed (L.E.B.T.) on 6 key aspects of CPR education: (1) assessing scene safety, (2) checking victim responsiveness, (3) activating emergency medical services, (4) properly positioning hands, (5) using an accurate rate of compression (100-120 per minute), and (6) using an appropriate depth (2-2.5 in [5-6 cm]).⁶ Those that demonstrated 5 or more criteria were considered high quality. Videos were also coded according to whether they taught current, hands-only CPR technique and specifically addressed barriers to performing CPR on women. Videos from the American Heart Association and American Red Cross were separately evaluated. Data collection occurred in April and May 2019. Data were analyzed with Excel version 16.16.22 (Microsoft).

Results

From 874 videos, 38 were excluded because of noninstructional or humorous content. Next, 184 were excluded for showing pediatric CPR or CPR on animals. Fourteen videos that were not in English, showed in-hospital locations, or were duplicates were also excluded. Of the remaining videos, 628 (98.4%) featured a man experiencing cardiac arrest or a unisex manikin without female anatomy. Some of these videos showed live action, and others featured animation. There were 10 unique videos (1.6%) featuring a woman experiencing cardiac arrest (8 actors, 1 manikin, and 1 animated character) (Figure 1).

Figure 1. Search Strategy and Selection for Online Instructional Cardiopulmonary Resuscitation (CPR) Videos Using the Search Term “How To Do CPR”.

From these 10 videos, only 4 were considered high quality (correctly addressing ≥5 key aspects of CPR training). Furthermore, 3 of the 4 high-quality instructional videos taught rescue breathing, which is no longer a recommended component of bystander CPR in the US. None of the films addressed barriers to performing CPR on a woman (Figure 2).

Figure 2. Online Cardiopulmonary Resuscitation (CPR) Instructional Films That Showed a Woman Receiving CPR and Satisfied Training Quality Indicators.

AED indicates automatic external defibrillator; EMS, emergency medical system.

We separately evaluated online videos (available on YouTube) by the American Heart Association and American Red Cross, given their dominant role in CPR education in the US. Of the freely available online resources from these organizations (including clips from commercial products), 2 featured women experiencing cardiac arrest. One American Red Cross video was instructional for automated external defibrillator placement but not CPR, while the other was demonstration only and not educational. Neither addressed female-specific barriers to automated external defibrillator use or CPR.

Discussion

Online, easily accessible instructional videos are an important source of public CPR education. Of the 638 identified videos in this study, only 1.6% featured a woman experiencing cardiac arrest, with the remaining 98.4% featuring a man or a unisex, nonfemale manikin. Only 1 high-quality video was identified that taught modern, hands-only CPR on a woman. None of these videos specifically addressed barriers to performing CPR on a woman.

There was a striking scarcity of female-specific CPR instructional videos freely available online and a complete lack of videos specifically addressing barriers to performing CPR on a woman. Improved sex representation in CPR instructional videos is an important step to addressing sex disparities in bystander CPR. However, this is not enough. Female-specific CPR barriers (eg, navigation of breast anatomy) must be explicitly addressed in future CPR educational videos to begin addressing—and eventually reducing—sex disparities in CPR.