Teaching Basic Life Support to Students of Public and Private High Schools

Abstracts

Background:

Despite being recommended as a compulsory part of the school curriculum, the teaching of basic life support (BLS) has yet to be implemented in high schools in most countries.

Objectives:

To compare prior knowledge and degree of immediate and delayed learning between students of one public and one private high school after these students received BLS training.

Methods:

Thirty students from each school initially answered a questionnaire on cardiopulmonary resuscitation (CPR) and use of the automated external defibrillator (AED). They then received theoretical-practical BLS training, after which they were given two theory assessments: one immediately after the course and the other six months later.

Results:

The overall success rates in the prior, immediate, and delayed assessments were significantly different between groups, with better performance shown overall by private school students than by public school students: 42% ± 14% vs. 30.2% ± 12.2%, p = 0.001; 86% ± 7.8% vs. 62.4% ± 19.6%, p < 0.001; and 65% ± 12.4% vs. 45.6% ± 16%, p < 0.001, respectively. The total odds ratio of the questions showed that the private school students performed the best on all three assessments, respectively: 1.66 (CI95% 1.26-2.18), p < 0.001; 3.56 (CI95% 2.57-4.93), p < 0.001; and 2.21 (CI95% 1.69-2.89), p < 0.001.

Conclusions:

Before training, most students had insufficient knowledge about CPR and AED; after BLS training a significant immediate and delayed improvement in learning was observed in students, especially in private school students.

Cardiopulmonary Resuscitation; Education; Basic Life Support; High School Students

Fundamento:

Embora recomendado como parte obrigatória do currículo escolar, o ensino de suporte básico de vida (SBV) ainda não foi implementado no ensino médio na maioria dos países.

Objetivo:

Comparar o conhecimento prévio e o grau de aprendizado imediato e tardio entre alunos do ensino médio de uma escola pública e outra privada, após capacitação em SBV.

Métodos:

Inicialmente, trinta alunos de cada escola responderam a um questionário sobre ressuscitação cardiopulmonar (RCP) e o uso do desfibrilador externo automático (DEA); em seguida, receberam treinamento teórico-prático de SBV e foram reavaliados imediatamente e seis meses após o curso.

Resultados:

As taxas de acertos dos alunos de ambas as escolas nas avaliações prévia, imediata e tardia apresentaram diferenças estatisticamente significantes e melhor desempenho da escola privada em relação à escola pública nas três avaliações, respectivamente, 42% ± 14% vs. 30,2% ± 12,2%, p = 0,001; 86% ± 7,8% vs. 62,4% ± 19,6%, p < 0,001 e 65% ± 12,4% vs. 45,6% ± 16%, p < 0,001. A razão de chance do total das questões mostrou um melhor rendimento da escola privada em relação à pública nas três avaliações, respectivamente: 1,66 (IC95% 1,26-2,18), p < 0,001; 3,56 (IC95% 2,57-4,93), p < 0,001 e 2,21(1,69-2,89), p < 0,001.

Conclusões:

Antes do treinamento, a maioria dos estudantes tinha um conhecimento insuficiente sobre RCP e DEA; após o curso de SBV, observou-se uma melhora significativa tanto imediata como tardia no aprendizado dos estudantes, notadamente para os alunos da escola privada.

Ressuscitação Cardiopulmonar; Educação; Suporte Básico de Vida; Estudantes do Ensino Médio

Introduction

Although the potential beneficial effect of cardiopulmonary resuscitation (CPR) has been well established, less than one in three victims of out-of-hospital witnessed cardiopulmonary arrest (CPA) receive lifesaving help from a bystander¹. In Brazil, it is estimated that approximately 200,000 CPAs occur annually, with half of the cases occurring out-of-hospital environment². In 2004, the American Heart Association (AHA) recommended that American schools establish a goal to train all teachers and students in CPR³, in agreement with the guidelines of the International Liaison Committee on Resuscitation (ILCOR), which a year earlier strongly recommended the inclusion of Basic Life Support (BLS) in the school curriculum^{4 , 5}.

Since then, many U.S. states and some European countries have included the teaching of BLS into the curriculum of high-school students and use of automated external defibrillator (AED)⁴, as did Norway, which since the beginning of the sixties has established the compulsorily teaching of CPR to schoolchildren⁶.

Schools are ideal laboratories to teach the population about basic techniques that comprise BLS⁷, considering that adolescents are usually able to perform chest compressions with the same efficacy as adults⁸ and are usually present at the scene of a medical emergency, such as homes, malls, airports, stadiums etc.⁵; in Brazil, approximately 8.4 million students are enrolled in high school and of these, 86% study in public schools⁹.

However, there is no current legislation that guarantees compulsory BLS training in schools or studies comparing the performance of students in CPR between public and private schools. On the other hand, to produce indicators of education and assist education managers in the evaluation of quality, equity and efficiency of teaching and learning, it is necessary to measure and compare the performance and the skills developed by the students¹⁰. Thus, the aim of this study was to evaluate and compare the prior knowledge and the degree of immediate and delayed learning among high-school juniors attending one public and one private high school, after training in BLS and use the automated external defibrillator (AED).

Methods

The present is a longitudinal, prospective study, carried out in one public and one private school, both in the city of Maceió, state of Alagoas, Brazil. These schools were chosen because they had a significant number of participants in the National High School Exams (ENEM) of 2009 and rank among the best in their respective categories. Inclusion criteria were: to be enrolled in the junior year of high school in the selected school; to be chosen by the school coordinator to participate in the project and sign, along with parents or tutors, the free and informed consent form. Exclusion criteria were: students who had had training in CPR and those who could not attend all activities.

The data collection tool was a questionnaire with 15 multiple-choice questions on general knowledge of basic life support distributed as follows: three questions related to the identification of a CPA; four questions regarding the correct sequence of CPR maneuvers; two questions related to compression/ventilation; three questions related to the management of the AED and three questions related to knowledge about CPR and sudden death. Each correct answer was worth 1 point and, therefore, 15 points (the maximum possible score) corresponded to a success rate of 100%.

First, the students answered the questionnaire. After that, they received theoretical and practical training lasting 180 minutes, given by two medical students according to the following sequence: theoretical background of BLS, chain of survival, correct CPR performance with emphasis on chest compressions, AED use and correct positioning of the victim after recovery in accordance with the international scientific consensus of 2010^{11 , 12}. On the same day, and immediately after the theoretical-practical session, the students were reassessed through the same questionnaire. Six months after the course was administered and without previous knowledge of the students regarding the scheduling, the medical students returned to the schools and reapplied the same questionnaire. The same material was used in both schools for practical activities: two adult CPR training manikins (CPR-80CA - Simulacare); disposable masks for mouth-to-mouth breathing and an automated external defibrillator for training (AED Trainer - Cmos Drake). The project was approved by the Ethics Committee in Research of the Federal University of Alagoas, under N. 005604/2011-54.

Statistical Methods

Categorical variables were compared using Fisher's exact test. Continuous variables were expressed as percentages and mean ± standard deviation (for normal distribution) or median with 25^th and 75^thpercentiles (for non-normal distribution), tested for normality using D'Agostino-Pearson omnibus test and analyzed with Student's ttest or nonparametric Mann-Whitney test.

To identify possible differences in learning among students from the same school, analysis of variance (ANOVA) for repeated measures (followed by Tukey's test) or Kruskal-Wallis test for non-normally distributed data were used. The total odds ratio (OR) and the OR of each question with 95% confidence intervals (95%CI) was calculated to compare the differences in prior knowledge and learning between students of the two schools. Statistical significance was considered as a p value < 0.05 or when the 95%CI of the odds ratio excluded the value 1.

Sample size was calculated at 19 students for each school, considering a significance level of 0.05 (two-tailed) and a statistical power of 85% to detect a 20% difference in learning, based on the results of the ENEM 2009, which showed a mean difference between the two schools of 24% with an estimated standard deviation of 20%¹³. Considering the risk of nonparticipation, the number of students in each school was increased.

Results

Of the eighty-seven volunteers who initiated the activities, thirty students from each school (seven males in each group) answered all three questionnaires. Eighteen and nine students from the public and private schools, respectively, refused to participate in the second or third evaluation. The mean age in the public school was slightly older than in the private school: 16.8 ± 0.70 years vs. 16.5 ± 0.68 (p = 0.04). Both schools showed no significant differences regarding gender (p = 1.0).

The rates of correct answers of public school students in the prior, immediate and at six months after training were, respectively, 30.2% ± 12.2% (95% CI: 25.7% to 34.8%); 62.4% ± 19.6% (95% CI: 55.1% to 69.8%) and 45.6% ± 16% (95% CI: 39.6% to 51.5%). When compared, these rates were significantly different (Figure 1). On the other hand, the rates of correct answers of private school students in the prior, immediate and at six months after training were, respectively, 42% ± 14% (95% CI: 36.5% to 47%); 86% ± 7.8% (95% CI: 82.6% to 88.5%) and 65% ± 12.4% (95% CI: 60.2% to 69.5%). When compared, these rates were also significantly different (Figure 2).

Figure 1
Means of correct answers with 95% confidence intervals in the prior, immediate and late evaluations among public school students

Figure 2
Means of correct answers with 95% confidence intervals in the prior, immediate and late evaluations among private school students

After, the questions related to the identification of CPA, the correct sequence of CPR maneuvers, the compression/ventilation ratio and AED management were grouped and analyzed, they showed a significant overall increase in knowledge after training with satisfactory late retention of learning among students from both schools (Tables 1 and 2).

Table 1
Rates of correct answers given by Public School students to grouped questions

Grouped Questions	Prior Evaluation	Immediate Evaluation	Delayed Evaluation	p (ANOVA / Kruskal- Wallis)
CPA - Identification (%)	31 ± 23	59 ± 27	40 ± 28*	< 0,001
CPR - Maneuvers (%)	19 ± 19	47 ± 21	47 ± 32†	< 0,001
Compression/Ventilation ratio (%)	25 ± 34	100 (50 - 100)	48 ± 31	< 0,001
AED - Management (%)	34 ± 28	67 ± 28	62 ± 29†	< 0,001

• Data expressed as mean ± standard deviation or median and 25-75th interquartile range.
• ^*
  p > 0.05 vs. Prior Evaluation;
• ^†
  p > 0.05 vs. Immediate evaluation. CPA: Cardiopulmonary arrest; CPR: Cardiopulmonary resuscitation; AED: Automated external defibrillator.

Table 2
Rates of correct answers given by Private School students to grouped questions

Grouped questions	Prior Evaluation	Immediate Evaluation	Delayed Evaluation	p (ANOVA / Kruskal- Wallis)
CPA - Identification (%)	28.8 ± 23	80 ± 24	46 ± 30	< 0.001
CPR - Maneuvers (%)	38 ± 27	100 (67 - 100)	67 (33 - 100)	< 0.001
Compression/Ventilation ratio (%)	50 (0 - 50)	100 (100 -100)	100 (50 - 100)*	< 0.001
AED - Management (%)	43 ± 32	84 ± 19	69 ± 17	< 0.001

• Data expressed as mean ± standard deviation or median and 25-75th interquartile range.
• ^*
  p > 0.05 vs. immediate evaluation. CPA: Cardiopulmonary arrest; CPR: Cardiopulmonary resuscitation; AED: Automated external defibrillator.

Public School vs. Private School

The rates of correct answers among the public school students were significantly lower than those of private schools in the three assessments, as shown in Figure 3. Table 3 shows the odds ratios for the fifteen questions in the three moments between students of the two schools. In the prior evaluation, the private school students showed higher numbers of correct answers in most questions, although only one of them showed statistical significance; after the training, this trend persisted and the private school students were significantly better in 7 and 8 of the fifteen questions, respectively, at the immediate and delayed evaluations.

Figure 3
Comparison of means of correct answers with 95% confidence intervals in the prior, immediate and late evaluations among students from public and private schools

Table 3
Odds ratio (OR) between the private and public schools with their respective 95% confidence intervals (95% CI) for the fifteen questions in the prior, immediate and delayed evaluations

Questions		Prior Evaluation			Immediate Evaluation				Delayed Evaluation
		OR (95%CI)		p		OR (95%CI)		p		OR (95%CI)		p
Total		1.66 (1.26 to 2.18)		< 0.001		3.56 (2.57 to 4.93)		0.0001		2.21 (1.69 to 2.89)		< 0.001
1		2.10 (0.71 to 6.22)		0.28		1.00 (0.36 to 2.75)		1.00		3.76 (1.04 to 13.7)		0.07
2		1.64 (0.53 to 5.12)		0.57		1.64 (0.53 to 5.12)		0.57		1.00 (0.34 to 2.93)		1.00
3		0.35 (0.10 to 1.16)		0.14		8.11 (1.61 to 40.8)		0.010		1.00 (0.36 to 2.76)		1.00
4		0.14 (0.02 to 1.23)		0.10		1.30 (0.31 to 5.40)		1.0		7.86 (1.96 to 31.7)		0.003
5		2.36 (0.63 to 8.92)		0.33		36.0 (8.10 to 160)		0.0001		3.50 (1.11 to 11.0)		0.05
6		2.51 (0.83 to 7.64)		0.17		50.1 (5.97 to 420)		0.0001		53.6 (3.00 to 957)		< 0.001
7		3.06 (0.97 to 9.66)		0.09		2.07 (0.18 to 24.2)		1.00		0.38 (0.13 to 1.09)		0.12
8		2.29 (0.80 to 6.50)		0.19		7.00 (1.38 to 35.5)		0.02		4.03 (1.37 to 11.9)		0.012
9		1.16 (0.40 to 3.35)		1.00		2.67 (0.92 to 7.70)		0.11		1.96 (0.70 to 5.48)		0.30
10		2.33 (0.81 to 6.73)		0.19		10.5 (1.23 to 90.7)		0.03		5.23 (1.66 to 16.5)		0.007
11		1.31 (0.47 to 3.60)		0.80		7.25 (0.82 to 64.5)		0.10		12.3 (2.46 to 60.9)		< 0.001
12		0.86 (0.29 to 2.55)		1.00		1.96 (0.70 to 5.48)		0.30		0.55 (0.18 to 1.62)		0.41
13		18.3 (3.67 to 91.2)		< 0.001		7.00 (1.38 to 35.5)		0.02		4.30 (1.41 to 13.1)		0.02
14		1.71 (0.62 to 4.77)		0.44		4.46 (0.47 to 42.5)		0.35		2.67 (0.84 to 8.46)		0.16
15		2.19 (0.72 to 6.70)		0.27		23.0 (1.26 to 420)		0.005		10.4 (0.53 to 201)		0.12

When the grouped questions were compared, the private school students showed, in the immediate evaluation, significantly higher number of correct answers related to the recognition of the CPA, the correct CPR sequence and AED management (Figure 4); at the late evaluation, this superiority was markedly repeated for the questions concerning CPR maneuvers and compression/ventilation ratio; however, there were significant only for the latter (Figure 5).

Figure 4
Rates of correct answers of grouped questions given by students from public and private schools at the immediate evaluation

Figure 5
Rates of correct answers of grouped questions given by students from public and private schools six months after training.

Both schools, after the training, obtained rate increases that exceeded 100% of correct answers when compared to baseline knowledge in the immediate evaluation (p < 0.001). After six months of training, such increase was still statistically significant compared to baseline knowledge: 53% for the public school and 55% for the private school (p < 0.001), demonstrating satisfactory increase and retention of knowledge by the students (Figure 3).

Discussion

This study showed that students in the junior year of high school from public and private high schools showed high rates of learning immediately after receiving the course on basic life support, as well as a satisfactory level of proficiency when evaluated six months after the training, especially the private school students, which had a significantly higher performance in the three evaluations in relation to the public school students.

Studies comparing BLS teaching among students of public and private high schools are scarce. Parnell et al¹⁴ assessed the knowledge and attitudes regarding resuscitation of high school students in New Zealand and found slightly higher rates of knowledge among private school students when compared to public school students, although both had low awareness of CPR principles. This was, however, a cross-sectional study in which a single questionnaire was applied to a mixed population of students trained and not previously trained in CPR.

Miró et al⁷, in a longitudinal study, assessing the influence of several factors associated with learning in students from high schools in Barcelona, Spain, observed satisfactory levels of immediately learning and after one year of training in CPR, respectively, 58% and 42%, with significantly better results for students from private schools. However, in this study, approximately 44% of the students had already participated in first-aid courses or were unable to inform that and, after a multivariate analysis, they found no independent association between private school teaching with performance and knowledge retention.

There is substantial evidence that retention of BLS knowledge and skills for its application rapidly decline after the initial training¹⁵. Several authors have studied this issue, but there is no consensus in the literature regarding the optimal time interval between trainings, which can vary according to the characteristics of the instructors, participants and their proportions, quality of theoretical and practical training and the evaluation results at the end of course¹⁶. Basic skills, such as asking for help, chest compression and ventilation, decrease three to six months after the training; however, these data are based on heterogeneous studies regarding the course's duration and design, characteristics of instructors and participants and frequency of participants' involvement in real resuscitations^{15 , 16}. Berden et al¹⁷, evaluating a group of nurses in noncardiac units, concluded that training every six months was enough to maintain satisfactory CPR skills. Woollard et al¹⁸, training laymen from a UK airport, observed that the interval in CPR and AED training should not exceed seven months. Moreover, Riegel et al¹⁹, studying lay volunteers, observed a satisfactory degree of retention in CPR and AED, even after 17 months of initial training.

In this study, in relation to general knowledge about CPR, it was observed that the percentage of correct responses in the immediate and late evaluations were significantly higher in the private school group in relation to the public school one; however, in relation to the AED management, public school students showed no significant differences when compared to the private school students in the late evaluation, or significant decrease in learning when assessed six months after the training. Apparently, the learning process with the AED is easier and the skills persist for a longer period than the CPR maneuvers^{19 , 20}.

This inequality of results unfavorable to the public school may be justified by a number of factors, such as lack of attention or motivation, less access to information, less qualified teachers, lower income, lower maternal education and availability of quality laboratories^{13 , 21} and is in agreement with the assessments of the Brazilian Education Development Index (IDEB) and ENEM results, which have successively shown throughout the country a superior performance of private schools students when compared to public school ones¹². According to the indicators produced by the National System of Basic Education Assessment (SAEB), 96% of students in the senior year of high school with difficulties in reading and interpreting texts of different literary genres are enrolled in public schools, while 76 % of students with reading skills of more complex argumentative texts study in private schools²⁰.

The insistence in incorporating the teaching of CPR in the school curriculum is based on the fact that children and adolescents trained in CPR are likely to discuss the training with siblings, friends and other family members, raising awareness about BLS and the demand for traditional training courses, which will result in the increase in the number of adults trained in CPR in the community²². The sooner they are trained, the better is the retention rate in formal courses²², and even elementary school students already have sufficient cognitive skills to correctly apply the AED²³.

However, there are potential barriers for the introduction of a training program in schools²⁴, particularly those involving cost and time availability in the curriculum; additionally, many students and lay people are not willing to provide care due to fear of infection, shock, legal consequences and risk of harming the victim²⁵. Moreover, the use of AEDs is hindered by the availability of trained staff and lack of familiarity and responsibility with the device²⁶. In the U.S., in 2000, a Federal Law was passed in order to reduce such barriers against the placement and use of AEDs in public areas. Since that time, these devices are already available in many public places such as airports, malls, gyms and public offices⁵. In Brazil, there is no specific legislation requiring the installation of AEDs in public and private environments.

Some studies that compared the standard theoretical-practical training in BLS with theoretical courses only using videos showed conflicting results^{27 , 28}. Thus, we chose to use in this study a theoretical-practical approach, performed by medical students who showed to be qualified, motivated, willing to devote time to scientific projects, and who had already successfully participated in several studies on the teaching of CPR^{29 - 31}.

Limitations

This study did not use a practical test as an evaluation tool. Although the written test should not replace the practical test on an individual assessment, it can be a viable alternative as a tool to estimate and compare the efficacy of psychomotor skills, especially in collective training programs^{32 , 33}. The theoretical evaluation used in this study, although based on multiple-choice questions prepared by the AHA, has not been validated in previous studies. And finally, the fact that students showed a satisfactory acquisition of knowledge during the course does not necessarily indicate a good performance of psychomotor skills during CPR in the real world³².

Conclusions

To the best of our knowledge, this is the first study that identified and directly compared the stages of prior, immediate and delayed knowledge after the theoretical and practical instruction on CPR and AED, among high school students from public and private schools. We observed that students from both schools had inadequate prior knowledge about BLS, but after theoretical and practical training, the students, particularly those from the private school, showed considerable increase in this knowledge with satisfactory persistence of such information, even after six months of training. However, considering the importance of the subject, the universal presence of schools in adolescents' lives and the inevitable decline in the levels of learning, we suggest a definitive incorporation of the BLS teaching as a compulsory subject in the curriculum of public and private high schools in the country.

• Sources of Funding
  There were no external funding sources for this study.
• Author contributions
  Conception and design of the research: Fernandes JMG, Leite ALS, Auto BSD, Rivera IR, Mendonça MA; Acquisition of data: Leite ALS, Auto BSD; Analysis and interpretation of the data and Writing of the manuscript: Fernandes JMG, Leite ALS, Auto BSD, Lima JEG; Statistical analysis: Fernandes JMG; Critical revision of the manuscript for intellectual content: Fernandes JMG, Rivera IR, Mendonça MA.
• Study Association
  This study is not associated with any thesis or dissertation work.

Acknowledgements

We thank Professors Roohelmann Pontes Silva, from Escola Estadual Moreira e Silva and Ernesto Stadler and João Thomaz Neto, from Colégio Contato Maceió, for supporting this project, as well as the students of the participating schools for their commitment to establish new knowledge. We are also grateful to Professor Maria Aparecida Silva and Dr. Fabiana Yulita for the correction and review of the manuscript.

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Publication Dates

• Publication in this collection
  06 June 2014
• Date of issue
  04 July 2014

History

• Received
  13 Sept 2013
• Reviewed
  02 Dec 2013
• Accepted
  17 Jan 2014