Bystander cardiopulmonary resuscitation training in primary and secondary school children in China and the impact of neighborhood socioeconomic status

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Introduction
Early and effective bystander cardiopulmonary resuscitation (CPR) has become the most important predictor of survival and long-term quality of life in out-of-hospital cardiac arrest (OHCA) patients, [1][2][3] as emergency-medical-services personnel may not arrive in time to prevent neurological damage. Importantly, studies show that bystanders who have received previous CPR training are most likely to perform CPR at the time of an OHCA. [4,5] Primary and secondary school children are an ideal target audience for bystander CPR training. The World Health Organization has endorsed school bystander CPR training programs, [6][7][8] which has been successfully implemented in many countries. [9][10][11][12] Studies on bystander CPR training for primary and secondary school children in China are limited; however, evidence suggests that effective bystander CPR training programs in Chinese schools could have long-term health benefits for the population. [13][14][15] Neighborhood socioeconomic status (SES) is a well-known determinant of health outcomes, the incidence of some diseases, and mortality. [16,17] Recent studies demonstrate that individuals from low-SES neighborhood, characterized by lower levels of education and income, have less knowledge of bystander CPR and a lower probability of initiating bystander CPR compared to individuals from higher-SES neighborhood. [18,19] No data currently describe the impact of neighborhood SES on bystander CPR training in school children.
The objectives of the current study were to assess bystander CPR training in school children in China and the impact of neighborhood SES on.

Trial design
A prospective controlled trial was conducted in seven schools in Zhejiang province. This study was approved by the Ethics Committee of The First Affiliated Hospital of Zhejiang University and registered in Chinese Clinical Trial Register, and the registration number is ChiCTR-HOC-16009680.
2.2. Bystander CPR training program 2.2.1. Theoretical bystander CPR. Theoretical bystander CPR education was conducted in instructor-led classes using a multimedia format and a brief video tutorial demonstrating bystander CPR. The course content was based on the 2015 European Resuscitation Council Guidelines [20] and emphasized the importance of bystander CPR, recognition of cardiac arrest, and emergency procedures.

Practical bystander CPR.
Practical bystander CPR training was held immediately after theoretical teaching and was conducted in instructor-led one-on-one classes using Laerdal Little Anne training manikins. Five students were assigned into 1 group according to their student numbers. And then each group was randomly assigned to 5 instructors. The course was conducted based on the guidelines from 2015 European Resuscitation Council and lasted until all the participants were capable of performing CPR.
Subsequently, students participated in a simulated basic life support (BLS) scenario. Skills were assessed using a scoring sheet (Supplementary Appendix A, http://links.lww.com/MD/C533) developed from the 2015 European Resuscitation Council Guidelines and the Cardiff Test for BLS and Automated External Defibrillation Version 3.1: Assessment Guidelines. [7,20] The assessment included evaluation of the consciousness, calling for emergency help, performing chest compression, and airway management.

Pretraining and post-training questionnaires
Students independently completed a 10-statement questionnaire that was distributed and collected by specified personnel before and after theoretical bystander CPR training. Questionnaires (Supplementary Appendix B, http://links.lww.com/MD/C533) were designed according to previous research, [21] while considering the actual situation in China. These questionnaires collected demographic information and assessed each student's willingness to learn first aid and their level of bystander CPR knowledge. Each question was scored on a 10-point scale, with a maximum score of 100 possible for the whole questionnaire.

Participants
Seven schools in 4 cities in Zhejiang province, China participated in this study. The 4 cities were from different socioeconomic regions. Primary and secondary school children from the fifth and sixth grade and the first and second grade, respectively, were included. Physically disabled or injured students are excluded. Course instructors were medical students or anesthesiologists from Zhejiang University who had successfully completed the cognitive and skills evaluation in accordance with the curriculum of the American Heart Association BLS instructor Program.

Study outcomes
The primary outcome of the investigation was the correct rate of CPR knowledge-related items. Secondary outcomes were the impact of neighborhood SES and age on the training.

Statistical analysis
Statistical analyses were performed using SPSS 17.0 for Windows (SPSS Inc, Chicago, IL). Categorical variables were presented as percentages and median (Q1, Q3), and were analyzed using the chi-squared test. Between-group differences were evaluated using t test for normally distributed variables and the Mann-Whitney U test for non-normally distributed variables.
Subgroup analyses stratified according to neighborhood SES was performed. According to Chiang et al, neighborhood SES was assessed based on the average price of real estate in the administrative districts where the schools were located. [22] Seven schools from 6 administrative districts were included in this study. The 2 districts with the lowest average price of real estate were classified as low-SES neighborhoods, and the other districts were classified as higher-SES neighborhoods. P < .05 was considered statistically significant.

Demographic characteristics
A total of 1093 students from 4 primary (492 students) and 3 secondary (601 students) schools in Zhejiang, China were enrolled in this study. Initially, a total of 8 schools in Zhejiang province were selected to participate in this study. Among these, 7 schools indicated a strong motivation to adopt a bystander CPR training curriculum (87.5%). One school was concerned that students would incorporate bystander CPR training into their games, creating potentially dangerous situations. Consequently, we emphasized that bystander CPR is only applicable to the person with cardiac arrest in emergency situations. No student suffered physical discomfort or injury during training.
The demographic characteristics of students who participated in this study are presented in Table 1. Among these, 990 (90.58%) and 1079 (98.72%) students completed the pretraining and post-training questionnaires, respectively.

BLS skills
The students from 5 schools participated in the BLS scenario. When assessing BLS skills and considering students with an 80% performance rate for each skill, 93.66% (458/489) of students called the manikin loudly, shook it gently to evaluate responsiveness, and contacted the Chinese medical emergency telephone number (120) for help; 98.16% (480/489) of students could put the manikin in the recovery position; 98.57% (482/ 489) of students could provide compressions with the correct hand placement; 96.73% (473/489) and 95.50% (467/489) of students used the correct compression rate and depth; 90.59% (443/489) of students performed compressions with the correct posture; 94.89% (464/489) of students were aware of the airway opening, and 96.93% (474/489) of students ventilated correctly; 91.00% (445/489) of students knew performing 30 chest compressions followed by 2 breathes. Overall, 92.84% (454/ 489) of students performed bystander CPR proficiently.

The impact of neighborhood SES and age on training
Significantly more students from the low-SES neighborhoods were unfamiliar with CPR (44.74% vs. 13.09%, P < .001) and were unwilling to share the acquired bystander CPR knowledge (27.91% vs. 20.85%, P < .05) compared with the students from the higher-SES neighborhoods ( Table 5).
Regardless of age, students from the low-SES neighborhoods scored worse on the pretraining questionnaire. Exceptions were scores on questions related to compression depth, rate, and the ratio of compression to artificial respiration. Scores for the latter items were low among students in both groups, and there were no significant differences (Table 6). On the post-training questionnaire, students from the low-SES neighborhoods who were 13 to Table 2 Pretraining questionnaire: attitudes and practical experience of bystander cardiopulmonary resuscitation.

Question n (%)
Have   14 years old performed better, and those who were 11 to 12 years had a similar performance on most assessment items compared to students from the higher-SES neighborhoods. Across all age groups, students from the low-SES neighborhoods did as well as students from the higher-SES neighborhoods on the total scores of the BLS skills assessment (Table 7).

Discussion
This study revealed that primary and secondary school children in China had little pretraining knowledge of CPR. However, with training, there was a significant improvement in the basic theory and skills of CPR. Students from low-SES neighborhoods had less pretraining knowledge of CPR. However, their performance was similar with students from higher-SES neighborhoods on the post-training questionnaire and the skills assessment, and better among students aged 13 to 14 years. Bystander CPR training for children is essential, as it ensures that they will have the skills to act in an emergency. This would strengthen safety in the community and improve cardiac survival rates. Furthermore, bystander CPR training may satisfy future employment requirements. Primary and secondary school children are focused, curious for knowledge, and motivated to learn new skills. In addition, they are likely to share newly acquired information with their parents and friends. Therefore, training student bystander CPR would result in more people acquiring BLS skills in the long term.
In the present study, we found a significant improvement in all aspects of bystander CPR after the theoretical training program.
These findings were especially pertinent to the knowledge of the depth, the rate for compression, and the ratio of compression to artificial respiration. And the percentage of them was increased from 7.58% to 72.94%, 8.18% to 72.57%, and 28.89% to 76.55%, respectively. Our findings suggest that Chinese primary and secondary school children could effectively learn bystander CPR theoretical knowledge by training. Previous studies have confirmed that bystander CPR learning could increase the awareness of first aid and improve outcomes of OHCA. [1,6,10,11,23] In fact, the students were not confident performing practical bystander CPR on the manikin after the theoretical training in our study. Therefore, practical training was conducted subsequently. After guided-practice, 92.84% of school children performed bystander CPR proficiently and 82% of school children had an excellent performance (scoring >90 points on a scale of 0-100 points). In accordance with these findings, previous studies have shown that school children in Europe and North America are able to acquire BLS skills after practical training. [10,11,24] These results show that theoretical combined with practical training is a feasible and effective method for primary and secondary school children in China.
In our study, scores on topics such as the compression depth, rate, and the ratio of chest compression to artificial respiration were low. These findings are in accordance with the results of the previous study. [13] This situation may suggest that Chinese primary and secondary school students have little pretraining knowledge of CPR and an urgent need for first aid knowledge.
In addition, our study showed that students from low-SES neighborhoods had less CPR knowledge before training and Table 4 Post-training skills assessment (simulated basic life support scenario) (n = 489).   worse performance on pretraining questions. The continuous urbanization and industrialization has caused the labor force from low-SES neighborhoods to enter cities, leaving their children behind with few resources at home in China. Such differences may be due to the lack of public health education and the shortage of medical resources in low-SES neighborhoods. Students from low-SES neighborhoods were not willing to share the CPR knowledge with others (27.91% vs. 20.85%, P < .05), which may be attributed to insufficient knowledge and no confidence. After training, 13 to 14 years old students from low-SES neighborhoods had the best performance on the posttraining questionnaire. All the students from the low-SES neighborhoods, independent of age, did as well as ones from higher-SES neighborhoods on total scores for the skills assessment. As rural children comprise approximately 30% of China's pediatric population, the present study highlights the importance of bystander CPR education and training in schools in low-SES neighborhoods in China Lack of knowledge of BLS skills, fear of performing bystander CPR incorrectly, and concerning about legal liability associated with poor outcomes following the administration of bystander CPR may be the main reasons for low initiating bystander CPR. [15] This suggests that legislative support is essential if bystander CPR training programs are to be universally popularized in China.

Limitations
This study was associated with several limitations. First, the generalizability of the findings to other regions in China remains unknown. Second, although the study demonstrated immediate improvements in knowledge and skills of bystander CPR, mastery requires retraining and practice regularly. Third, the ethnic factors, immigrants and the students who did not present on the day of training were not considered. Further studies aimed at developing bystander CPR training programs suitable for younger children are warranted.

Conclusions
School children in China have a poor pretraining knowledge of bystander CPR. However, with training, there was a significant improvement in the basic theory and skills. Bystander CPR training efforts should be targeted to Chinese primary and secondary school children, especially in low-SES neighborhoods. Table 7 Results of the post-training questionnaires and BLS skills after training stratified according to neighborhood socioeconomic status and age.