Cardiopulmonary resuscitation for lay people: Evaluation of videos from the perspective of digital health literacy

Abstract Objective: to analyze the quality indicators and technical content of the videos for lay people posted on the YouTube platform, on cardiopulmonary resuscitation in adults and their audiovisual production regarding the principles of digital health literacy. Method: a descriptive and exploratory study, which selected videos recorded between December 2015 and April 2021. They were analyzed by indicators of the production of audiovisual material, considering the American Heart Association guidelines and the principles of digital health literacy. Descriptive and inferential statistics were performed. Results: of the 121 videos analyzed, 26 did not comply with any indicator on cardiopulmonary resuscitation, four reached 81% compliance, eight videos reached 79%, nine reached 69% and 74 videos, from 6% to 63%. According to the principles of digital health literacy, one video met 85% of the indicators, 81 met from 50% to 80% and 39, from 10% to 49%. A positive correlation was identified between literacy and cardiopulmonary resuscitation. Conclusion: no video presented 100% compliance with the American Heart Association guidelines. The absence of mechanisms for supervision and control over health-related contents allows for the posting of mistaken videos, which have been used as a learning method by people and can thus miss their greatest goal: save lives.


Introduction
Cardiopulmonary Arrest (CPA) consists in the interruption of blood and respiratory supply due to lack of heartbeats or to their ineffectiveness. It occurs suddenly and, in most cases, in non-hospital environments. If there is no fast and effective care, it may cause death or leave serious sequelae that will compromise the person's quality of life (1) . This condition can be reversible if cardiopulmonary resuscitation (CPR) is performed, which consists in an organized sequence of maneuvers that will restore spontaneous bloodstream, properly and at the right moment (2) .
These maneuvers should be initiated by those who witness the CPA or first approach the victim. Usually, lay people have this initial contact and need to know how to act quickly, in order to contribute to survival and reduce the risk of injury to the victims (3-4) .
The Internet has been an immediate source of health information, which often does not consider people's digital health literacy (DHL) (5) . It is defined as "the ability to seek, find, understand and evaluate diverse health information from electronic sources and apply the knowledge acquired to address or solve a health problem" (6) . In addition to that, non-screening of the quality of the materials posted results in a high risk of misinformation (7) .
One of the most popular and accessed online platforms with billions of views every day is YouTube, emerging as a significant and vast source of health information (8)(9) . Considering the number of people who access educational videos for health and the absence of quality criteria for posts, concern arose to evaluate the diverse information related to CPR, available in this virtual environment.
In addition to considering the individual skills on access and use of the diverse information made available digitally, the material presented must contain information based on updated scientific evidence, be easily accessible and understandable (10) . The concern in relation to contents

Method Design, locus and data collection period
This is an exploratory and descriptive research study with a quantitative approach. Data collection was carried out on the YouTube video content sharing platform (http:// www.youtube.com.br). This platform was chosen among other websites because it is the most used research social media in Brazil and the second most visited site in the world (11) .
Data collection was carried out between 2020 and 2021, including videos recorded between December 2015 and April 2021. The content of the CPR videos was evaluated based on the American Heart Association guidelines (12)(13) , which are international references systematically updated every five years. Periodic updating of the AHA guidelines during data collection did not interfere with evaluation of the videos, as they were directed to the health professionals' performance.
Videos on cardiopulmonary resuscitation in adults published in Portuguese and lasting a maximum of 4 minutes were included. "Short" videos are the most accessed by YouTube users (14)(15) , with greater potential to be viewed and thus contributing to the educational aspects related to cardiopulmonary resuscitation (16) . The short length of videos and images evidences a change in the visualization and thinking patterns, making the products desirable for those who seek this information (17) .
Videos that did not directly refer to CPR for lay people were excluded.

Data collection and analysis
As a first step, a search was carried out in the Health Sciences Descriptors to identify the controlled descriptors related to the topic, namely: "cardiopulmonary reanimation", "cardiopulmonary resuscitation" and "cardiopulmonary resuscitation for lay people".

Subsequently, filters offered by the website itself
were applied that delimited the search results: "type of result", "videos" and "length" (selecting those of "short length -less than 4 minutes"). addresses, in order to assemble the display list and enable as many visits as necessary.
To guide data collection, the authors prepared two checklists, one to evaluate pertinence of the content considering the American Heart Association current guidelines (12)(13) , and another to verify adequacy of the videos considering the criteria established for the production of educational materials in digital media (11,17) .
In order to ensure greater reliability of the data collected, the checklists were submitted to an evaluation by professionals working in the areas of cardiopulmonary resuscitation and health literacy. such as animations, subtitles or graphic elements) (18) .

Data analysis
All variables of the video evaluation instrument were stored in an electronic spreadsheet, with the aid of Microsoft Excel ® . Descriptive statistics were performed.

Results
Of the 350 videos identified on the YouTube platform, 34.6% met the eligibility criteria. The flowchart in Figure   1 shows the stages of the data collection process, which consisted in the identification, screening and selection of the videos evaluated.

No video had 100% compliance with the American
Heart Association guidelines (12)(13) . Nearly 26 videos did not meet the items in the instrument on CPR, four reached 81% compliance, eight reached 79%, nine met 69% of the items and 74 videos reached from 6% to 63% compliance. The number of videos in accordance with the AHA guidelines can be identified in Figure 2.
Of the 121 videos analyzed, 40.5% were produced by health professionals and students. The frequency of items met in relation to the evaluation of the diverse information on CPR is presented in Table 1.

Discussion
It is a fact that videos are excellent didactic resources in the teaching-learning process and facilitate the dynamic propagation of diverse information. However, those who are willing to produce them should be aware of the quality of the content to be transmitted. In this context, analyzing the quality of the videos on cardiopulmonary resuscitation in one of the largest online platforms in the world made it possible to verify that the benefits of this social media can be reduced by the low level of digital health literacy of its users and by the neglect regarding the content posted (19) .
The results of the current study evidenced lack of mastery or attention on the correct way to act in a Correct application of the CPR procedures was not observed in most of the videos, which generates concern in times when technology is gradually gaining more space each day and imposes changes in the learning process.
People who watch these videos will perform the maneuver inappropriately, not achieving the greatest goal of saving lives (27) .  (12) .
In addition to that, the importance of chest return after the compressions in order not to compromise venous return and cardiopulmonary blood flow, adequate speed with a frequency of 100 to 120 compressions per minute in adult victims, non-interruption of CPR until arrival of the rescue team that will take the automatic external defibrillator, and site safety verification to avoid complications both in the victim and in the person who is providing assistance, represent essential information for adequate care in the face of a CPA situation (12) .
Absence of this information can lead the lay rescuers to errors and even interfere with the victims' survival rate.
It is known that the survival rate after a CPA event can triple when high-quality and early CPR is performed (29) .
Once again, this reinforces that most of the videos directed to lay people that are posted on YouTube on this theme should not be recommended as a learning method, although it is undeniable that YouTube videos can contribute to the teaching-learning process of the population. Thoughtful planning should be carried out, with control of the content conveyed by the digital platform, allowing it to be used with all the capacity it offers (16,30) .
One aspect to be considered in the elaboration of health-related videos, which may assist in the quality of a research source, should pay attention to this care in its posts (16,30) .
Currently, the Internet and social networks represent the main channels for seeking health information and peer support. However, the benefits of social media on health can be reduced by the low level of digital health literacy, and it is indispensable that the information is organized and accessible enough so that the users can find it and apply it for their own health (31) .
The videos that had the highest number of items met were the most viewed and with the highest number of likes. This indicates more acceptability by the users regarding the content. Credibility of the information is an indispensable attribute to ensure that the CPR techniques are especially adopted for the lay person, and that it requires basic digital literacy conditions.
In addition to lack of mastery of the technique, digital skills are also missing on the part of the authors, and the schools should start including the health literacy curriculum in their pedagogical plans in order to train professionals who are responsive to literacy. In addition to that, digital health is already a global reality and it is up to the training schools to prepare future professionals to meet the demands of this new reality, based on ethics and on the promotion of safe health in the digital environment (32) .
Both quality of the content and of the video production should be factors taken into consideration.
Although it is not difficult to produce a video, the technical aspects must be taken into account, as the producers may not only designate materials to achieve particular purposes, but take responsibility for conveying information on the effective use of such materials, which may exert an impact on people's lives (33)(34) .
Most of the authors of the videos analyzed in this study did not inform if they were health professionals or students; many of them only reported their names.
However, use of technical terms was observed; some were dressed as health professionals and used mannequins in the simulations; others were in educational institution environments, therefore presuming that they were health professionals or students.
When posting content on a public access virtual platform, identification (name and profession) of those who are in charge of that post should be included in the material, as this information generates trust in the production (35) .
A study (18) pointed out that criteria that convey reliability to the videos and that guarantee maintenance of their quality are the identification and the production date of the video, as they inform the timeliness of the content presented. This same study pointed out that the objective of the video should be obvious to the viewer; it should have a title that clearly reflects its purpose; and in no case the title should be misleading about the content that will be presented (18) .
In situations where health terminologies are used, it is important that they are accessible to the audience to be reached; the necessary technical terms must be defined. In addition to that, it is important to reference the diverse information that is being used since, in addition to proving from where the information was extracted, it demonstrates scientific and ethical care. Appropriating content without giving due credit to the source is unethical and may result in legal actions (36)(37) .  (38)(39) . In addition to that, the number of videos related to CPR in children (60% of those found) points to prospects for future studies that analyze the quality of videos in this age group.

Conclusion
The results evidenced weaknesses in the diverse information on cardiopulmonary resuscitation available on