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Cardiopulmonary resuscitation (CPR) training for adolescents is a prominent strategy to increase the number of community first responders who can recognize cardiac arrest and initiate CPR. More schools are adopting technology-based CPR training modalities to reduce class time and reliance on instructor availability and increase their capacity for wider training dissemination. However, it remains unclear whether these technology-based modalities are comparable with standard training.
This study aimed to systematically review and perform meta-analyses to evaluate the effectiveness of technology-based CPR training on adolescents’ CPR skills and knowledge.
Searches were conducted in PubMed, Embase, Cochrane Library, Ovid MEDLINE, CINAHL, PsycINFO, Education Resources Information Center, ProQuest Dissertations and Theses Global, and Scopus from inception to June 25, 2021. Eligible randomized controlled trials (RCTs) compared technology-based training with standard training for adolescents aged 12 to 18 years. Studies were appraised using the Cochrane risk-of-bias tool. Random-effects meta-analyses were performed using Review Manager (The Cochrane Collaboration). Subgroup analyses were conducted to explore sources of heterogeneity. Overall certainty of evidence was appraised using the Grading of Recommendations Assessment, Development, and Evaluation approach.
Seventeen RCTs involving 5578 adolescents were included. Most of the studies had unclear risks of selection bias (9/17, 53%) and high risks of performance bias (16/17, 94%). Interventions that included instructor guidance increased the likelihood of adolescents checking the responsiveness of the person experiencing cardiac arrest (risk ratio 1.39, 95% CI 1.19-1.63) and calling the emergency medical services (risk ratio 1.11, 95% CI 1.00-1.24). Self-directed technology-based CPR training without instructor guidance was associated with poorer overall skill performance (Cohen
Instructor-guided technology-based CPR training that includes hands-on practice and real-time feedback is noninferior to standard training in CPR skills and knowledge among adolescents. Our findings supported the use of technology-based components such as videos, computer programs, or mobile apps for self-directed theoretical instruction. However, instructor guidance, hands-on practice, and real-time feedback are still necessary components of training to achieve better learning outcomes for adolescents. Such a blended learning approach may reduce class time and reliance on instructor availability. Because of the high heterogeneity of the studies reviewed, the findings from this study should be interpreted with caution. More high-quality RCTs with large sample sizes and follow-up data are needed. Finally, technology-based training can be considered a routine refresher training modality in schools for future research.
Out-of-hospital cardiac arrests (OHCAs) are associated with poor survival and neurological outcomes [
Standard CPR training involves didactic face-to-face lessons, skill demonstrations by qualified instructors, and hands-on practice on manikins in small groups [
International resuscitation guidelines suggest the incorporation of technology into CPR training as alternatives to standard training [
Two systematic reviews were conducted on CPR training modalities for adolescents. Plant and Taylor [
This study adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [
Searches were conducted in PubMed, Embase, Cochrane Library, Ovid MEDLINE, CINAHL, PsycINFO, Education Resources Information Center, ProQuest Dissertations and Theses Global, and Scopus from inception to June 25, 2021. The search terms included
Randomized controlled trials (RCTs) were included if they met the following criteria: (1) participants were adolescents aged 12 to 18 years; (2) participants received CPR training that included technology-based components such as videos, web-based learning, computer programs, mobile apps, or manikin software with real-time feedback; (3) technology-based CPR training was compared with standard CPR training (without the technology-based intervention component); and (4) the RCTs reported CPR skills or knowledge. CPR skills are defined as the ability to perform CPR techniques objectively measured via manikin software or as evaluated by instructors. Theoretical knowledge scores are measured by self-reported instruments, including multi-item questionnaires or multiple-choice–question tests (
Inclusion and exclusion criteria.
Variable | Inclusion criteria | Exclusion criteria |
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Study design | RCTsa and cluster RCTs | Nonrandomized studies, observational studies, qualitative studies, and reviews |
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Publication type | Full-text journal publications, conference proceedings, and unpublished dissertations or theses | Editorials and letters |
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Publication year | No limit | N/Ab |
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Language | English only | Languages other than English |
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Population | Schoolchildren aged 12 to 18 years | Schoolchildren with physical disabilities that may affect their ability to perform CPRd (eg, those who are blind, deaf, or have a speech disability) |
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Intervention | CPR training with technology-based components, including videos, computer programs, mobile apps, and real-time audiovisual feedback | CPR training with popular songs only |
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Comparison | Standard resuscitation training without technology-based component | N/A |
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Skill performance | Overall performance (cumulative score from skills checklist); components of cardiopulmonary resuscitation, including checking responsiveness, checking the airway and breathing, calling the EMSe, compression depth, compression rate, correct hand position, correct compression:ventilation ratio, total compressions, correct ventilation, AEDf pad placement, and use of AED | N/A | |||||||||
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Knowledge | Theoretical knowledge scores | N/A |
aRCT: randomized controlled trial.
bN/A: not applicable.
cPICO: Population, Intervention, Comparison, and Outcomes.
dCPR: cardiopulmonary resuscitation.
eEMS: emergency medical services.
fAED: automated external defibrillator.
All retrieved records were imported into EndNote X9 (Clarivate) for deduplication. Titles and abstracts of records were screened by 2 independent reviewers (AL and WX) for relevance. After removing irrelevant records, full texts of potential studies were independently assessed for eligibility. Discrepancies were resolved through discussion with a third reviewer (BS).
AL and WX collected data independently using a standardized data extraction form. Extracted data included publication year, country, study design, setting, participants, sample size, interventions, comparators, outcome measures, and instruments. Posttraining and retention data were extracted, with retention defined as at least 4 weeks after training. Indicators of trial quality were also extracted; for example, attrition rate, intention to treat, and trial registration. Results of studies reported in >1 publication were extracted as 1 study. Authors were contacted when data were incomplete or unclear. Discrepancies in extracted data were resolved through discussion with BS.
AL and WX performed quality appraisal independently for all included studies. Discrepancies were resolved through discussion with BS. The Cochrane risk-of-bias tool was used to appraise studies for risks of bias [
Meta-analyses were performed with Review Manager (The Cochrane Collaboration) and presented as forest plots where appropriate. The Mantel-Haenszel approach and risk ratio (RR) were selected for dichotomous outcomes, whereas the inverse-variance approach pooled mean differences (MDs) for continuous outcomes. Continuous outcomes measured using different scales were presented as standardized MDs or Cohen
Heterogeneity was evaluated using the Cochran
The preparation of this paper did not involve primary research or data collection involving human participants; therefore, no institutional review board examination or approval was required.
The search process is illustrated in
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.
Characteristics of the included studies.
Study authors, year; country | Study design | Sample size | Technology-based training | Standard training | Outcomes | Attrition (%) | ITTa; missing data management | Protocol; trial registration; funding |
Beskind et al [ |
Three-arm cluster RCTb,c | Id: 58, Ce: 54 | Brief video | Standard instructor-led training | Skills | 11.2 | No; no | No; no; yes |
Chamdawala et al [ |
Two-arm RCT | I: 110, C: 110 | QCPRf real-time visual feedback | Standard instructor-led training | Skills and knowledge | 13.6 | No; no | No; no; yes |
Cortegiani et al [ |
Two-arm RCT | I: 60, C: 65 | QCPR real-time visual feedback | Standard instructor-led training | Skills | 13.2 | No; no | Yes; yes; no |
Cuijpers et al [ |
Three-arm RCT | I1: 33, I2: 34, C: 37 | I1: 1 hour e-learning+1 hour instructor-led training, I2: 1 hour e-learning | Standard instructor-led training | Skills | NRg | NR; NR | NR; NR; NR |
Doucet et al [ |
Two-arm RCT | I: 83, C: 82 | StartnHart app | Standard instructor-led training | Skills | 0 | N/Ah | No; no; no |
Han et al [ |
Two-arm RCT | I: 31, C: 31 | e-Learning+videoconferencing | Standard instructor-led training | Skills | 0 | N/A | No; no; yes |
Iserbyt et al [ |
Two-arm RCT | I: 59, C: 69 | Video instruction | Static picture instruction | Skills | 7.2 | No; no | No; no; no |
Marchiori et al [ |
Two-arm cluster RCT | I: 187, C: 144 | Video game | Standard instructor-led training | Knowledge | 3.8 | No; no | No; no; yes |
Morrison et al [ |
Two-arm RCT | I: 140, C: 124 | CPRi Anytime video self-instruction+instructor-led training for AEDj | Standard instructor-led training | Skills | 21 | NR; NR | NR; NR; NR |
Nord et al [ |
Two-arm cluster RCT | I: 645 or 208, C: 587 or 224 | Web course+classroom-based instructor-facilitated training with app (static pictures) or video instruction | Classroom-based instructor-facilitated training with app (static pictures) or video instruction | Skills and knowledge | 13.6 | No; no | No; yes; yes |
Norman [ |
Three-arm RCTc | I: 39, C: 39 | Video instruction | Standard instructor-led training | Skills and knowledge | 17.1 | No; no | NR; NR; NR |
Onan et al [ |
Three-arm cluster RCT | I1: 25, I2: 25, C: 25 | I1: video instruction, I2: video instruction with real-time feedback | Standard instructor-led training (theory only) | Skills and knowledge | 7.2 | No; no | No; no; no |
Otero-Agra et al [ |
Four-arm cluster RCT | I1: 151, I2: 140, I3: 109, C: 89 | I1: mandatory and graded team-based training with real-time feedback for competition, I2: mandatory and graded individual training with real-time feedback, I3: individual training with real-time feedback | Standard instructor-led training | Skills | 0 | N/A | No; no; no |
Reder et al [ |
Four-arm cluster RCTc | I1: 213, I2: 170, C: 206 | I1: interactive computer session, I2: interactive computer session with practice | Standard instructor-led training | Skills and knowledge | 22.8 | No; no | No; no; NR |
Rezaei et al [ |
Two-arm cluster RCT | I: 42, C: 42 | Prerecorded video demonstration | Standard instructor-led training | Skills and knowledge | 0 | N/A | No; no; yes |
Van Raemdonck et al [ |
Four-arm RCTc | I1: 44, I2: 42, C: 43 | I1: video instruction, I2: video instruction with low-cost manikin | Standard instructor-led training | Skills | 66.3 | No; no | No; no; yes |
Yeung et al [ |
Three-arm cluster RCT | I1: 21, I2: 24, C: 19 | I1: Lifesaver app, I2: Lifesaver app+standard instructor-led training | Standard instructor-led training | Skills | 21 | No; no | No; yes; yes |
aITT: intention to treat.
bRCT: randomized controlled trial.
cOne comparison arm was not included in this review because of an irrelevant comparator.
dI: intervention.
eC: control.
fQCPR: quality cardiopulmonary resuscitation.
gNR: not reported.
hN/A: not applicable.
iCPR: cardiopulmonary resuscitation.
jAED: automated external defibrillator.
All studies adhered to national or international resuscitation guidelines, except for the study by Rezaei et al [
The standard training used included face-to-face qualified-instructor–led demonstration, with hands-on practice on manikins. Other comparators included static pictures [
Most (12/17, 71%) of the studies had overall moderate risk of bias (
Risk-of-bias (A) summary and (B) graph.
Overall performance is the cumulative score from a skills checklist, with components presented in
Meta-analyses: cardiopulmonary resuscitation skill components.
Outcome and time point | Trials (N=16), n (%) | Arms (N=23), n (%) | Sample size (N) | Statistical approach | Effect estimate (95% CI) | Overall effect | |||||||||||||||
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After training | 5 (31) | 6 (26) | 884 | M-Ha, random effects | 1.16b (0.90 to 1.50) | 1.14 | .25 | 88 | |||||||||||
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After training | 5 (31) | 6 (26) | 1370 | M-H, random effects | 0.93b (0.78 to 1.10) | 0.85 | .39 | 60 | |||||||||||
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Retention | 2 (13) | 3 (13) | 892 | M-H, random effects | 0.90b (0.72 to 1.13) | 0.89 | .37 | 25 | |||||||||||
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After training | 4 (25) | 5 (22) | 719 | M-H, random effects | 1.18b (0.92 to 1.50) | 1.31 | .19 | 68 | |||||||||||
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After training | 6 (38) | 7 (30) | 996 | M-H, random effects | 1.10b (0.92 to 1.31) | 1.07 | .28 | 81 | |||||||||||
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Retention | 2 (13) | 2 (9) | 511 | M-H, random effects | 1.01b (0.92 to 1.10) | 0.14 | .89 | 0 | |||||||||||
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After training | 3 (19) | 4 (17) | 824 | IVe, random effects | 23.96f (19.84 to 28.09) | 11.40 |
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After training | 10 (63) | 13 (57) | 1619 | IV, random effects | 1.16f (–2.49 to 4.82) | 0.62 | .53 | 95 | |||||||||||
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Retention | 6 (38) | 8 (35) | 1179 | IV, random effects | 0.73f (–3.07 to 4.52) | 0.38 | .71 | 94 | |||||||||||
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After training | 6 (38) | 8 (35) | 1447 | M-H, random effects | 1.04b (0.90 to 1.21) | 0.54 | .59 | 43 | |||||||||||
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Retention | 2 (13) | 3 (13) | 528 | M-H, random effects | 0.76b (0.59 to 0.97) | 2.17 |
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After training | 11 (69) | 15 (65) | 2107 | IV, random effects | –3.25f (–7.57 to 1.07) | 1.47 | .14 | 88 | |||||||||||
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Retention | 6 (38) | 8 (35) | 1179 | IV, random effects | –2.47f (–7.48 to 2.54) | 0.97 | .33 | 85 | |||||||||||
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After training | 5 (31) | 7 (30) | 601 | M-H, random effects | 0.89b (0.75 to 1.07) | 1.22 | .22 | 38 | |||||||||||
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After training | 7 (44) | 10 (43) | 1617 | M-H, random effects | 0.93b (0.84 to 1.03) | 1.38 | .17 | 44 | |||||||||||
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Retention | 3 (19) | 5 (22) | 1021 | M-H, random effects | 0.86b (0.65 to 1.14) | 1.06 | .29 | 56 | |||||||||||
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After training | 8 (50) | 11 (48) | 1680 | M-H, random effects | 0.86b (0.67 to 1.10) | 1.23 | .22 | 69 | |||||||||||
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Retention | 3 (19) | 5 (22) | 1056 | M-H, random effects | 0.64b (0.41 to 0.99) | 2.00 |
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After training | 2 (13) | 2 (9) | 597 | M-H, random effects | 0.99b (0.87 to 1.13) | 0.15 | .88 | 34 | |||||||||||
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After training | 2 (13) | 3 (13) | 614 | IV, random effects | –22.84f (–30.35 to –15.33) | 5.96 |
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After training | 2 (13) | 3 (13) | 729 | M-H, random effects | 0.94b (0.86 to 1.02) | 1.58 | .11 | 54 | |||||||||||
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After training | 2 (13) | 3 (13) | 729 | M-H, random effects | 0.98b (0.94 to 1.01) | 1.15 | .25 | 68 |
aM-H: Mantel-Haenszel.
bRR: risk ratio.
cEMS: emergency medical services.
dCPR: cardiopulmonary resuscitation.
eIV: inverse variance.
fMD: mean difference.
gResults of significance are presented in italics.
hAED: automated external defibrillator.
Of the 16 RCTs included in the meta-analyses for posttraining performance, 6 (38%; arms: 8/23, 35%) involving 1121 students reported overall performance scores from skills checklists [
Subgroup analyses based on instructor guidance: overall performance scores.
Subgroup analyses | Comparisons (n) | Effect estimate (95% CI) | Subgroup effect | Subgroup differences | ||||||
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Self-directed learning | 2 | –0.74 (–1.02 to –0.45) | 5.02 |
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0 | 92.8 |
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Instructor-guided learning | 6 | 0.28 (–0.17 to 0.73) | 1.22 | .22 | 88 | N/Ab | N/A |
aResults of significance are presented in italics.
bN/A: not applicable.
Of the 16 RCTs, 3 (19%; arms: 4/23, 17%) involving 727 students reported overall performance at 6 months [
Meta-analyses performed for CPR skill components are summarized in
Of the 16 RCTs, 3 (19%; arms: 4/23, 17%) involving 824 students reported overall compression quality calculated by manikin software (
Meta-analysis: overall compression quality.
Subgroup analyses: cardiopulmonary resuscitation skill components after training and at retention.
Subgroup analyses | Comparisons (n) | Effect estimate (95% CI) | Subgroup effect | Subgroup differences | |||||||||||||||||||||||
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Self-directed learning | 3 | 1.07 (0.83 to 1.38) | 0.50 | .61 | 86 | 67 |
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Instructor-guided learning | 3 | 1.39 (1.19 to 1.63) | 4.10 |
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0 | —b | — | ||||||||||||||||||
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Self-directed learning | 4 | 0.84 (0.75 to 0.94) | 3.05 |
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0 | 4.6 | .31 | ||||||||||||||||||
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Instructor-guided learning | 2 | 1.02 (0.71 to 1.48) | 0.13 | .90 | 63 | — | — | ||||||||||||||||||
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Self-directed learning | 4 | 1.10 (0.85 to 1.43) | 0.72 | .47 | 85 | 0 | .93 | ||||||||||||||||||
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Instructor-guided learning | 3 | 1.11 (1.00 to 1.24) | 2.01 |
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0 | — | — | ||||||||||||||||||
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Self-directed learning | 6 | –3.16 (–8.17 to 1.85) | 1.23 | .22 | 93 | 83.9 |
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Instructor-guided learning | 7 | 3.94 (1.50 to 6.37) | 3.17 |
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78 | — | — | ||||||||||||||||||
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Self-directed learning | 5 | 0.84 (0.71 to 0.99) | 2.10 |
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48 | 64.1 |
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Instructor-guided learning | 5 | 1.11 (0.83 to 1.47) | 0.71 | .48 | 74 | — | — | ||||||||||||||||||
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Hands-on practice | 11 | 2.20 (0.08 to 4.32) | 2.03 |
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79 | 70.6 |
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Without practical training | 2 | –6.52 (–15.53 to 2.50) | 1.42 | .16 | 94 | — | — | ||||||||||||||||||
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Hands-on practice | 13 | –5.47 (–9.26 to –1.68) | 2.83 |
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81 | 96.7 |
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Without practical training | 2 | 9.38 (5.75 to 13.01) | 5.07 |
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Hands-on practice | 6 | –3.88 (–9.79 to 2.03) | 1.29 | .20 | 86 | 62.1 |
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Without practical training | 2 | 1.80 (–1.67 to 5.27) | 1.02 | .31 | 0 | — | — | ||||||||||||||||||
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Video instruction | 4 | 0.78 (0.61 to 1.00) | 1.92 |
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0 | 9.3 | .33 | ||||||||||||||||||
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Computer program or mobile app | 5 | 0.99 (0.82 to 1.18) | 0.16 | .87 | 66 | — | — | ||||||||||||||||||
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Real-time feedback only | 1 | 0.93 (0.84 to 1.02) | 1.53 | .13 | N/Ad | — | — |
aResults of significance are presented in italics.
bNot available.
cEMS: emergency medical services.
dN/A: not applicable.
Instructor-guided training significantly increased the likelihood of checking the responsiveness of people experiencing cardiac arrest (RR 1.39, 95% CI 1.19-1.63;
Despite high heterogeneity levels, hands-on practice potentially increased mean compression depth. Technology-based training interventions yielded significantly deeper chest compressions in 36% (4/11) of the intervention arms [
Subgroup analyses of studies involving hands-on practice using different training modalities (
Video instruction significantly decreased the likelihood of correct hand position (RR 0.78, 95% CI 0.61-1.00;
Subgroup analysis: mean compression rate after training.
Technology-based training decreased the likelihood of correct compression depth (RR 0.76, 95% CI 0.59-0.97;
Of the 17 RCTs, 6 (35%; arms: 8/24, 33%) involving 2253 students reported knowledge scores using questionnaires [
Computer programs or mobile apps potentially improved knowledge scores (Cohen
Marchiori et al [
Overall, the effect of technology-based training on knowledge after training remains inconclusive. However, instructor guidance, hands-on practice, and computer programs or mobile apps potentially improved knowledge.
Meta-analysis on knowledge scores at 2 to 6 months pooled from 18% (3/17) of the trials (arms: 4/24, 17%), which involved 1862 students, revealed high heterogeneity (
Our review showed that technology-based CPR training involving instructor guidance, hands-on practice, and real-time feedback yielded favorable outcomes for secondary school and high school students after the intervention. Technology-based training also potentially improved overall skills performance and knowledge at retention.
Consistent with a recent meta-analysis conducted among laypeople and health care professionals [
The findings revealed that technology-based training with hands-on practice potentially increased compression depth. In all of the included studies, the mean compression depth ranged from 30 mm to 53 mm, less than the maximum acceptable compression depth of 60 mm [
In our review, real-time visual feedback improved overall compression quality, which comprises compression depth and rate, chest recoil, and hand position. Prior studies also reported that feedback devices contribute to improved chest compressions among health care professionals and adult laypeople [
However, video instruction reduced the likelihood of correct hand position. Similarly, an RCT [
Technology-based training potentially improved overall performance at 6 months. Similarly, prior studies demonstrated improved skill retention in adolescents for up to 8 months after technology-based training [
Our findings were consistent with those of a past meta-analysis [
However, knowledge questionnaires were not standardized across the studies. Recently, a questionnaire assessing adolescents’ CPR knowledge was developed and validated [
The strengths of this review include an extensive search in multiple bibliographic databases and comprehensive synthesis of results. However, the review was limited by the low quality of the included studies. Most (16/17, 94%) of the studies inadequately reported or took measures to reduce selection and performance biases. In addition, variations in intervention designs across the studies increased heterogeneity; for instance, videos and computer programs or mobile apps may emphasize theoretical knowledge, whereas interventions involving real-time feedback focused on CPR skills. Furthermore, several (11/17, 65%) of the technology-based interventions involved active interaction and engagement with students, whereas others (7/17, 41%) involved passive learning through videos. These variations made it challenging to draw conclusions on training elements required for optimal effectiveness. Finally, this review only included trials published in English.
More high-quality RCTs with clear descriptions of study procedures—for example, allocation concealment and blinding of participants and personnel—are needed. These efforts will improve the credibility of evidence and contribute to stronger conclusions on the effectiveness of technology-based training for adolescents. Future studies should consider incorporating learning theories to guide their interventions [
Overall, technology-based training demonstrated equivalence or improvements in skills and knowledge after training and at retention when compared with standard training among adolescents. From an educational perspective, the noninferiority of technology-based training offers a desirable alternative to standard training. Schools can consider using videos, computer programs, or mobile apps for self-directed theoretical instruction. However, instructor guidance and hands-on practice are still necessary components of training. Real-time feedback devices may also be used to increase students’ compliance to resuscitation guidelines. Such a blended learning approach, comprising technology-based resources and face-to-face teaching, may reduce class time and reliance on instructor availability and increase schools’ capacity for wider training dissemination. Furthermore, refresher training should focus on challenging skills; for example, compression depth and ventilation.
This review explored the use of technology-based training as an alternative to standard CPR training among secondary school and high school students. Our findings supported the use of technology-based components such as videos, computer programs, or mobile apps for self-directed theoretical instruction; these components potentially improve skills and knowledge retention. However, instructor guidance, hands-on practice, and real-time feedback are still necessary components of training to achieve better learning outcomes for adolescents. Such a blended learning approach may reduce class time and reliance on instructor availability. Regular refresher training is necessary for challenging skills such as compression depth and ventilation. Caution must be exercised when interpreting the results of this review because of the high heterogeneity of intervention characteristics. The overall low quality of evidence indicated the need for high-quality RCTs with large sample sizes and follow-up data.
Database search terms and keywords.
Descriptions of interventions.
Grading of Recommendations Assessment, Development, and Evaluation.
Results of subgroup analyses for skills and knowledge.
Subgroup analyses of knowledge after training.
cardiopulmonary resuscitation
mean difference
out-of-hospital cardiac arrest
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
randomized controlled trial
risk ratio
The authors would like to thank Ms Wong Suei Nee for reviewing the search strategies and Associate Professor Wilson Tam for his advice regarding data analysis.
None declared.