Background

Cardiac arrest, defined as the sudden cessation of cardiac activity with hemodynamic collapse, is the principal cause of death for patients with coronary artery disease (CAD) [1]. Survival after cardiac arrest is dependent upon recognition of the arrest, activation of the emergency response system, prompt initiation of bystander-performed chest compressions, early defibrillation and access to advanced life support and post-cardiac-arrest care (the “chain of survival”) [1, 2, 3, 4]. The incidence of bystander cardiopulmonary resuscitation (CPR) depends on recognition of the event, training level, and the willingness of a layperson responder to participate when a cardiac arrest occurs [3, 4]. “Willingness” to perform CPR reflects not only training, but also personal experiences, level of education, local cultures and norms, and attitudes, fears and beliefs regarding the risks and benefits of performing CPR on a stranger [5, 6, 7].

Costa Rica is a middle-income country in Central America, where the leading cause of death is CAD (16.4% in 2015) [8]. The Grand Metropolitan Area (GMA) of Costa Rica, a high-population density area surrounding the capital, San José, includes 50 percent of the Costa Rican population. The GMA has a robust Emergency Medical Services (EMS) prehospital and hospital system capable of managing cardiac arrest patients with Advanced Life Support; however, bystander CPR is rarely performed [9]. In a 2014 study of laypersons in San José, we found a high level of interest in taking CPR classes (55%) and a willingness to perform CPR in the event of a cardiac arrest (74%) [7]. A separate study of San José emergency physicians demonstrated that the vast majority (97%) believe that layperson CPR training would improve morbidity and mortality from out of hospital cardiac arrest (OHCA) under the current San José EMS system [9].

Our earlier study of laypersons in San José, Costa Rica found that while interest in taking CPR classes and willingness to perform CPR are high, they are not universal. Barriers exist, such as a lack of confidence in the effectiveness of CPR; there are also practical barriers to taking CPR classes, such as affordability, accessibility and lack of personnel trained to give CPR classes. Other significant barriers to registering for CPR classes or expressing willingness to perform CPR on a stranger include the fear of legal consequences and hesitancy to perform mouth-to-mouth ventilations [9]. Many of these barriers have also been identified in low-income and Latino neighborhoods in the United States [5, 6].

One approach to circumventing the fear of mouth-to-mouth ventilation and decreasing the complexity of bystander CPR has been the implementation of hands-only (compressions-only) CPR education for non-medical persons [10, 11]. Hands-only CPR™ (HOCPR) has even been shown to be superior to conventional CPR in certain settings; for example, studies by Cabrini et al. and Hüpfl et al. have shown higher rates of survival among out-of-hospital cardiac arrest (OHCA) victims who receive HOCPR versus conventional CPR [12, 13]. In one nationwide study in Japan, over an eight-year period (2005–2012), dissemination of HOCPR training for lay-rescuers was associated with a 47-fold (0.6 to 28.3 per 10 million) increase in survival with favorable neurological outcomes after OHCA [14].

Most conventional and HOCPR training programs have focused on adult learners. However, some countries (for example, Sweden and Norway) have incorporated CPR training as part of the curriculum in schools [15]. The American Heart Association (AHA) and others have suggested that students attending school may be an appropriate audience for CPR training [10, 15]. According to the AHA, “teaching CPR to school-aged children at the middle school level and higher is effective and may result in retention of the skills and knowledge” as well as changing the stigma and fear associated with performing CPR [10]. Incorporating CPR instruction into school curricula may be a sustainable way to teach CPR as well as a way to create a critical mass of laypersons within the community capable of performing CPR [10]. One successful study, performed in 1,131 public schools around the United States, utilized the AHA’s “CPR in Schools” kit as a means to educate middle school students, taking advantage of the personnel and infrastructure already in place in the public school system. Seventy-six percent of students stated they were comfortable with performing CPR post-instruction and performed an average of 34% better on a post-instruction quiz assessing knowledge of the correct steps of HOCPR, depth and rate of compressions, when to stop performing compressions, and the function of an Automated External Defibrillator [16].

The current study tests whether a Spanish-language, HOCPR video, developed by the AHA and validated among middle-school children in the United States, is an effective strategy for teaching Costa Rican age- and education-equivalent children to learn the steps of HOCPR.

Methods

Results

Three hundred and eight students, all ages 11–18 and enrolled in grades six through eleven, participated in the HOCPR classes. Fifty-one students were from Rio Azul, 13 from Tirrases, 93 from Isaac Phillipe, and 151 from José Fidel Tristán. All students completed quizzes before and after the intervention and were included in the analysis.

When considering all 308 students and the four questions combined, the students’ scores (mean percent correct) more than doubled after training (40.9% ± 1.4% before training vs. 92.5% ± 0.9% after training, p < 0.00001). Similar, statistically significant improvements were observed in each school, regardless of geographic location or poverty rate: Río Azul (46.1% ± 3.8% vs. 87.3% ± 2.8%, p < 0.00001); Tirrases (32.7% ± 6.6% vs. 78.9% ± 7.9%, p = 0.00014); Isaac Phillipe (37.6% ± 2.9% vs. 95.4% ± 1.0%, p < 0.00001); and José Fidel Tristán (42.1% ± 1.9% vs. 93.7% ± 1.1%, p < 0.00001) (Table 1).

Table 2 shows that students demonstrated improvement across all questions. Importantly, knowledge of the appropriate steps of HOCPR more than doubled after training (42.2% before training vs. 92.5% after training; p < 0.000001). After training, almost three-fourths (73%) of children reported they “would be comfortable” performing CPR on an individual who had suffered a cardiac arrest (Table 3).

Discussion

This study provides new information about the effectiveness of the American Heart Association’s “CPR Anytime” training program in improving CPR knowledge and confidence among middle and high school students in a middle-income Central American country. A brief intervention, consisting of an AHA video and hands-on manikin practice, significantly improved students’ knowledge of the steps involved in performing HOCPR.

Coronary Artery Disease (CAD) has become a major cause of morbidity and mortality among low- to middle-income countries in recent years, and in Costa Rica it has replaced trauma and infectious diseases as the principal cause of death [8]. In high-income countries, the morbidity and mortality from cardiac arrest, most commonly the result of CAD, has been reduced by training laypersons to perform CPR [1, 14, 15, 22, 23]. Of course, layperson (bystander)-performed CPR is only one of the critical links in the chain of survival. There must also be an EMS system that can respond to cardiac arrest patients with Advanced Life Support and trained personnel, and definitive treatment options must be available within the hospitals [4, 23].

The Grand Metropolitan Area of Costa Rica is one of the places that could benefit from mass layperson CPR training, given its well-developed pre- and in-hospital emergency care system capable of providing advanced life support and post-arrest care. Currently in the public ambulance sector, there are 24 bases of the Cruz Roja (Red Cross); two have 24 hours-per-day advanced life support, and five have advanced life support during certain hours. There are also 19 stations of bomberos (firefighters); four have 24-hours-per-day ALS ambulances.

Before implementation of a community CPR education program, cultural acceptability and local expert input must also be considered. Our group previously carried out a series of layperson and emergency physician focus groups and surveys to learn more about the barriers and facilitators to community CPR education in San Jose [7, 9]. We found that a majority of adult laypersons would be willing to take a CPR class (55%) and perform CPR on a cardiac arrest victim (73%), with few perceived barriers [7]. Importantly, a majority of local emergency physicians believed that community CPR education would be reduce morbidity and mortality from cardiac arrest within the current EMS system [9].

Given this local context, our group designed a pilot program based on a similar project carried out among middle-school students in Denver and Aurora, Colorado. The rationale is that schools may offer an efficient mechanism to reach large numbers of individuals to create a “critical mass” of laypersons trained in, and comfortable performing, CPR. School-based CPR training takes advantage of the existing educational personnel and facilities [10]. Importantly, the AHA “CPR Anytime” kits are designed to help non-medical personnel learn HOCPR, without the presence of a trained or certified instructor. Thus, these tools represent a resource-friendly way to disseminate important information to large numbers of people, requiring only an initial monetary investment. The “CPR Anytime” course does not seek to provide “certification;” rather, it teaches a simplified version of HOCPR, focusing on recognizing a cardiac arrest, calling the emergency response number and initiating compressions until arrival of an ambulance.

One strength of the current study is that the four schools represent a broad range of socioeconomic conditions. Rio Azul and Tirrases represent some of the poorest neighborhoods in the GMA, while the children who attend Isaac Phillipe tend to come from upper class families. Our study found that the educational intervention succeeded in all sites. We saw improvement in test scores (a significant doubling) and a high level of comfort (73%) performing HOCPR post-intervention in all groups. We sought to test the intervention in diverse communities because, traditionally, CPR education has been limited to individuals with the resources to pay for a class and the ability to take time from work to attend one [5, 6, 10, 11]. This study provides support for the cognitive effectiveness of HOCPR training, even in poorer communities where few individuals are able to attend or pay for formal classes. Our study also showed that the improvement in pre- and post-tests and levels of comfort post-intervention were similar for both Costa Rican and United States students. The United States pre- and post-test averages were 50% and 84%, respectively, as compared with the Costa Rican pre- and post-test averages of 41% and 93%. The levels of comfort after the classes for United States and Costa Rican students were 76% and 73%, respectively [16].

This study also has several limitations. First, it was conducted in a single metropolitan area in one country in Central America; the results may be different in other communities. Second, we only measured outcomes immediately after the intervention; the improvements in knowledge that we observed may not be sustained. The measured outcomes were also limited to an assessment of graded, written quizzes; psychomotor skills were not tested. A third limitation was the presence of researchers with prior CPR training during the CPR classes. Finally, even before the video and mannequin intervention, a relative high proportion of students (59.1%) reported they felt comfortable performing CPR on a cardiac arrest victim.

Although this study demonstrated the effectiveness of the “CPR Anytime” video and mannequin intervention among middle and high school children in the Grand Metropolitan Area of Costa Rica, future studies should test the effectiveness of train-the-trainer programs, in which local health educators are taught how to teach the classes in their respective schools. Additionally, a school-based CPR educational program may not be sustainable in these Costa Rican communities without buy-in and support from the bomberos, the Ministerio de Educación, the Cruz Roja or other community organizations.

Several obstacles and ethical challenges need to be considered before implementation of HOCPR education programs in low-income or resource-poor communities. Video-based educational tools require televisions, computers and other projection equipment that may be difficult to find in some areas. There must be a reliable source of electricity; during one of our team’s teaching days in Rio Azul, an electrical outage forced a postponement of the classes. In addition, the Grand Metropolitan Area is a unique site in Central America, in that it has a well-developed pre-hospital system capable of providing advanced life support to OHCA victims within a reasonable time frame [23]. In areas that do not have access to ambulances or trained personnel within a short window of time, the probability of survival from OHCA with good neurological outcome is vastly decreased. In these communities it may be unethical to expend resources to teach HOCPR to laypersons. Another consideration in many resource-poor communities is the relative unavailability of Automatic External Defibrillators, which are a proven adjunct to improve survival after OHCA.

Summary

Short, video- and mannequin-based CPR instruction may be a viable way to mass educate school-age children in low-resource areas where CAD represents a significant burden of disease and where there are pre-hospital and hospital systems capable of managing OHCA victims. Additional studies are needed to measure students’ CPR skills, longer-term knowledge retention and their ability to perform CPR in simulated cardiac arrest settings.

Additional File

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