
==== Front
Resusc Plus
Resusc Plus
Resuscitation Plus
2666-5204
Elsevier

S2666-5204(24)00206-6
10.1016/j.resplu.2024.100755
100755
Simulation and Education
Kids save lives: Who should train schoolchildren in resuscitation? A systematic review
Mollo A. anna.mollo@bluewin.ch
ab
Beck S. st.beck@uke.de
c
Degel A. antje.degel@charite.de
d
Greif R. tino.greif@erc.edu
ef
Breckwoldt J. jan.breckwoldt@usz.ch
a⁎
a Institute of Anesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
b Department of Internal Medicine, Spital Limmattal, Zurich, Switzerland
c Department of Intensive Care Medicine, Hamburg-Eppendorf University Medical Centre, Hamburg, Germany
d Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Hindenburgdamm 30, 12203 Berlin, Germany
e University of Bern, Bern, Switzerland
f Department of Surgical Science, University of Torino, Torino, Italy
⁎ Corresponding author at: Institute of Anesthesiology, Zurich University Hospital, University of Zurich, Switzerland. jan.breckwoldt@usz.ch
29 8 2024
12 2024
29 8 2024
20 10075518 6 2024
7 8 2024
15 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by/4.0/ This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Aim

CPR training for schoolchildren to increase bystander CPR-rates is widely applied. HCPs are regarded as the instructor gold standard, but using non-HCP instructors (e.g., peer-tutors, schoolteachers, medical students) challenges that. This systematic review assesses whether cardiopulmonary resuscitation (CPR) training for children led by peer-tutors, schoolteachers, or medical students results in different learning outcomes to training by health-care professionals (HCPs).

Methods

We searched studies that compared CPR training for schoolchildren (population) delivered by peer-tutors, schoolteachers, or medical students (intervention), with training led by HCPs (comparison), assessing student knowledge, skills, willingness and/or confidence to perform CPR (outcome). We included randomized and non-randomized controlled trials (study design). Medline, Embase, Psychinfo, Cinahl, Cochrane, Scopus, Web of Science, and Eric were searched from inception until December 23rd, 2023 (timeframe). Two independent reviewers performed title, abstract, full text screening, bias assessment, and grading of certainty of evidence. We followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) guidelines, and registered the review with PROSPERO.

Results

Of 9′092 studies identified, 14 were included. Comparison of intervention groups to HCP-led training showed similar overall results (knowledge, skills, self-confidence). Superior results for HCP training were only reported for ‘ventilation volume’, while schoolteachers and medical students achieved superior knowledge transfer. A meta-analysis was possible for ‘compression depth’ between peer-tutors and HCPs showing no significant differences. Certainty of evidence was ‘low’ to ‘very low’.

Conclusion

This systematic review of CPR training for school children revealed that peer-tutors, schoolteachers and medical students achieve similar educational outcomes compared to those of HCPs. Non-HCPs training schoolchildren is an appropriate cost-efficient alternative and easy to implement in school curricula.

Keywords

Systematic review
Resuscitation training
Basic life support
Schoolteachers
Peer-teaching
Kids-save-lives education
==== Body
pmcIntroduction

Outcome from out-of-hospital cardiac arrest (OHCA) strongly depends on layperson bystander cardiopulmonary resuscitation (CPR).1 CPR before the arrival of emergency services (EMS) can more than double survival rates.2, 3, 4, 5, 6, 7 Layperson CPR-training is associated with increased cardiac arrest recognition8 and higher likelihood of initiating CPR before EMS-arrival.7, 9 One way to achieve wide-spread CPR-training independent of socio-economic factors is to train schoolchildren.10 The ‘Kids-Save-Lives’ programme has been endorsed by the WHO since 201211 and was highlighted in a statement by the ‘International Liaison Committee on Resuscitation’ (ILCOR) in 2023.12, 13 Overall, regular CPR training for schoolchildren has been shown to generate and consolidate knowledge and skills in all age groups.12

While only a few countries have implemented mandatory training of CPR for schoolchildren, most of these programmes have been established on a voluntarily basis. These programmes suffer mainly from two often-quoted barriers: (a) difficulties integrating the programmes into school curricula and scheduling problems, and (b) limitations of resources, namely expenses for manikins and for instructors.14, 15 Certified health care professionals (HCP) are considered the ‘gold standard’ for CPR instructors, but they pose scheduling challenges within a school curriculum and produce extra costs. As an alternative, CPR training in schools delivered by non-HCP instructors (medical students, schoolteachers, peer-tutors, or combinations thereof) offer easier integration into school curricula at lower cost. 16, 17, 18. The ILCOR Scientific Statement suggests using schoolteachers for training, however, this suggestion has not been based upon a rigorous systematic review.12 Therefore, the aim of this study was to systematically assess the existing literature comparing the effect of HCP-led CPR training to CPR training by medical students, schoolteachers, or peer-tutors (‘alternative instructors’). We did not address other alternatives to HCP-led training (such as self-learning) to keep the focus on the question ‘who should instruct’.

Methods

This systematic review was registered at the Prospective Registry for Systematic Reviews (PROSPERO CRD42024491922) and followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA).19

We organized the research question according to the PICOST format (population, intervention, comparator, outcome, study design, timeframe).• Do schoolchildren (population),

• receiving CPR-training by peer-tutor, schoolteacher, or medical students (intervention)

• compared to those receiving CPR-training led by HCPs (comparator)

• show equivalent educational outcomes (knowledge, skills, willingness and/or confidence to perform CPR) after the CPR-training (outcome)?

• Peer-reviewed randomized controlled trials (RCTs) and non-randomized controlled studies (non-RCTs) were eligible (study design).

• Publications from inception of each database to the search date (23.12.2023) were included. No language limitations were set as long as an English abstract was available (timeframe).

Definitions

As ‘peer-tutors’ we defined schoolchildren either of the same age as their ‘trainees’ or older. In all cases, the more precise wording would be ‘near’-peers as the peers have some kind of preceding training and additional knowledge before their teaching task. ‘HCP instructor’, was defined as any person with a professional background in health care with some kind of an instructor qualification.

Selection of eligible articles

The search strategy was generated and conducted by an information specialist of the University of Zurich (Appendix A). We searched Medline, Embase, Psychinfo, Cinahl, Cochrane, Scopus, Web of Science and Eric. Finally, the reference lists of the included studies were screened by the first author for eligible studies that might have been missed by the search strategy. The inclusion criteria were: I) CPR training of schoolchildren, II) intervention group was trained by either peer-tutors, schoolteachers or medical students and III) the control group was instructed by HCPs. Exclusion criteria were: I) children’s median age >16 years, II) No control group, or control group that did not receive any training and III) Conference abstracts. For abstract screening, full text screening and the data collection processes, we used the software ‘Covidence’ [https://www.covidence.org]. All sources were screened by the first author and one additional author independently and conflicts were solved bilaterally through open discussion. In case of remaining discrepancies, a third reviewer was involved to achieve consensus. Data were extracted into Excel [https://www.microsoft.com/] sheets and comprised training formats, characteristics of schoolchildren, instructor training, and outcomes after training, including knowledge, skills, willingness to perform CPR and self-confidence at different post-intervention time points. For papers reporting graphic output only, we approximated the results based on the graphics.

Two independent reviewers conducted the risk of bias assessment with the Cochrane’s ‘Risk Of Bias 2′ (ROB2)-assessment for RCTs and the ‘Risk Of Bias In Non-randomised Studies – of Interventions’ (ROBIN-I) tool for non-RCTs at outcome level.20, 21 Authors of this review who were authors of eligible studies were excluded from assessment. Conflicts were resolved bilaterally through open discussion. Certainty of evidence was evaluated using the ‘Grading of Recommendations Assessment, Development and Evaluation’ (GRADE) tool.22

Synthesis methods & effect measures

We grouped the studies according to the instructors’ professional backgrounds and according to post-intervention outcome time points. Outcome assessment included short-term (end-of-course), mid-term (later than end-of-course, up to 12 months), and long-term learning (>12 months). Following the ‘Synthesis Without Meta-Analysis’ (SWiM) reporting guidelines, we created effect direction plots showing whether the study reported significant differences between the intervention and control group.23

For pooled studies reporting the skills “chest compression rate and depth” in suitable metrics, we tested homogeneity with the Cochrane’s Q test.24 When there was sufficient homogeneity, we calculated the effect size using inverse-variance random-effects models comparing standardized mean differences for continuous data and odds ratio for binary data (for studies reporting % of children passing the skills test). Due to methodological differences between study groups, it was not feasible to perform meta-analyses for the outcomes ‘knowledge’ or ‘willingness to perform CPR’ and ‘confidence’. Meta-analysis was performed with SPSS (IBM, version 29.0 for Mac). Results are presented as forest plots. A confidence interval of α = 0.05 was used for both homogeneity testing and effect size calculation.

Results

The search identified 9′092 articles, and two additional studies were found by hand search. After removing 4′685 duplicates, 4′409 articles were included into the title and abstract screening, and 340 full texts were assessed, of which 14 eligible studies were included in the final analysis (PRISMA Flow chart Fig. 1, Study characteristics Table 1).Fig. 1 Prisma Flow Diagram.

Table 1 Characteristics of included studies. RCT = randomized controlled trial, cRCT = cluster-randomized controlled trial, non-RCT = non-randomized experimental study. I = Intervention group, C = control group, yr = years.

Author, Year, Country	Study Design	Analyzed sample size	Intervention	Time of outcome	Outcomes	
Beck, 2015, Germany 25	RCT	I: 471, C: 466	Peer-led training	End-of-course	Skills	Skill assessment using a checklist	
Bohn, 2012, Germany 30	non-RCT	I: 78, C: 66	Schoolteacher-led training	6–12 months; ≥ 12 months (2 yr, 3 yr, 4 yr)	Skills, knowledge, self-confidence	CPR data registered by manikin.
Knowledge and self-confidence by questionnaire.	
Choi, 2015, Korea 26	non-RCT	I: 119, C: 68	Peer-led training	≤3 months	Knowledge, Willingness	Questionnaire	
Cuijpers, 2016, Netherlands 31	RCT	I1: 50, I2: 53, C: 41	I1: schoolteacher-led training; I2: medical students led training	End-of-course; ≤3 months	Skills	Skill assessment using a checklist (Cardiff Test).
CPR data registered by manikin.	
Damvall, 2022, Norway 27	non-RCT	I: 982, C: 76	Peer-led training	End-of-course; 6–12 months	Skills	CPR Data registered by manikin.	
Dîrzu, 2018, Romania 37	cRCT	I: 64, C: 64	Medical students led training	≤3 months	Skills, Knowledge	CPR data measured by manikin.
Knowledge by questionnaire.	
Haseneder, 2019, Germany 38	cRCT	I: 193, C: 192	Medical students led training	≤3 months; 6–12 months	Knowledge and Self-confidence	Questionnaire	
Jimenez-Fabrega, 2009, Spain 36	non-RCT	I: 219, C: 223	Schoolteacher-led training	End-of-course; 6–12 months	Knowledge	Questionnaire	
Lanzas, 2022, Portugal 32	non-RCT	I: 199, C: 121	Schoolteacher-led training	End-of-course; ≤3 months	Skills, Knowledge	Skill assessment using a checklist.
Compression rates counted manually.
Knowledge by questionnaire.	
Lukas, 2016, Germany 35	non-RCT	I: 99, C: 78	Schoolteacher-led training	6–12 months; >12 months (3 yr, 6 yr)	Skills, Knowledge, Self-confidence	CPR data measured by manikin.
Knowledge and confidence by questionnaire.	
Perez-Bailon, 2023, Spain 33	non-RCT	I: 327, C: 322	Schoolteacher-led training	End-of-course	Skills	Skill assessment using a checklist	
Sabihah, 2020, Malaysia 28	RCT	I: 18, C: 18	Peer-led training	End-of-course; ≤3 months	Skills, Knowledge	Skill assessment using a checklist.
Knowledge by questionnaire.	
Santomauro, 2018, Italy 29	non-RCT	I: 164, C: 156	Peer-led training	End-of-course	Skills	Skill assessment using a checklist.
CPR data registered by manikin.	
Yeung, 2023, Hong Kong 34	RCT	I: 161, C: 150	Schoolteacher-led training	End-of-course; 6–12 months	Skills, Knowledge, Willingness	Skill assessment using a checklist (only follow-up). Knowledge and willingness by questionnaire.	

Five studies analysed training by peer-tutors,25, 26, 27, 28, 29 seven by schoolteachers,30, 31, 32, 33, 34, 35, 36 and three by medical students.31, 37, 38 One study separately assessed both schoolteacher-led and medical student-led training, and therefore the study was included in both subgroups.31 The included studies were performed in Europe25, 27, 29, 30, 31, 32, 33, 35, 36, 37, 38 or Asia.26, 28, 34 Seven studies were RCTs, and seven were non-RCTs (prospective cohort studies). One follow-up study35 of a previous study30 (cohort overlap: 81.4%) was included as it provided additional data up to six years post-intervention. From another study comparing medical students with residents and emergency physicians,37 we only included the emergency physicians as HCPs. This study regarded the ‘resident’ group as a different competency level for training, and we wanted clear differences between intervention and control.

Children in all studies included were attending secondary school (age range: 10–18 years, average of the 7 RCTs25, 29, 31, 33, 36, 37, 38 was 14.4 years, median of the 7 non-RCTs30, 32, 34, 27, 28 was 15 years). At end-of-courses, 1635 children had been trained by their peers (control group n = 716), 956 by their schoolteachers (control group n = 857), and 53 by medical students (control group n = 41). Table 2 shows children included in the studies over time, whereas Supplemental Table 1 gives an overview of the durations of the training, the educational strategies used, and the instructors’ training.Table 2 Students included in studies pooled by intervention groups. Time of outcome: T1: end-of-course, T2: ≤3 months, T3: 6–12 months, T4: 2 years T5: 3 years, T6: 4 years, T7: 6 years. *: overlapping cohort of I = 99 and C = 78. I = Intervention group, C = C.

Intervention group	Number of studies for T1-T7	Number of recruited students	Number of trained students	Number of students analyzed at T1-T7	
Peer-led training	T1: n = 425, 27, 28, 29
T2: n = 226, 28
T3: n = 127	4177	4145	T1: I = 1635, C = 716
T2: I = 137, C = 86
T3: I = 259, C = 11	
Schoolteacher-led training	T1: n = 532, 33, 34
T2: n = 231, 32
T3: n = 430, 34, 35, 36
T5: n = 230, 35
T4&T6: n = 130
T7: n = 135	3475	2432	T1: I = 956, C = 857
T2: I = 209, C = 162
T3: I = 429, C = 422 *
T4 & T6: I = 78, C = 66
T5: I = 177, C = 144 *
T7: I = 99, C = 78	
Medical students led training	T1: n = 131
T2: n = 331, 37, 38
T3: n = 138	850	793	T1: I = 53, C = 41
T2: I = 310, C = 297
T3: I = 178, C = 179	

Knowledge and self-confidence were assessed by questionnaires. Skill-assessments was performed either by using checklists 25, 28, 29, 31, 32, 33, 34 or by measuring CPR data by the manikin software (for details, see Table 1).27, 35, 30, 31

Risk of bias and certainty of evidence

Risk of bias was rated from ‘low’ to ‘some concerns’ for RCTs, and ‘moderate’ to ‘serious’ for non-RCTs (Table 3.). The overall certainty of evidence was downgraded to ‘low’ or ‘very low’ due to risk of bias, inconsistency, and imprecision (supplemental Table 2).Table 3 Risk of bias assessment. A: ROB-2-Tool («Risk Of Bias for randomized trials”) for RCTs, B: ROBINS-I-Tool («Risk Of Bias in Non-randomized Studies – of Interventions») for non-RCTs.

	

Table 4 Effect direction plots depicting comparisons between the intervention and control group for A: peer-tutors, B: schoolteacher-led training and C: medical students led training. ⇔: No significant difference,⇑/⇓:significant difference. EMS = emergency services, C = compression, AED = automatic external defibrillator, V = ventilation, Vol. = volume, mths = months, yrs = years.

A)	
Peer teaching	
	Skills	Knowledge	Willingness	Confidence	
	Safety	Check response	Check breathing	Call EMS	C: Overall	C: Start	C: Depth	C: Rate	C: Position	C: Recoil	C: No flow time	AED	V: Rate	V: Vol.	Overall skills				
End-of-course	Beck25																			
Damvall27																			
Sabihah28																			
Santo-mauro29																			
≤3 months	Choi26																			
Sabihah28																			
6–12 months	Damvall27																			
B)	
teacher	
	Skills	Knowledge	Willingness	Confidence	
	Safety Check	Check response	Check breathing	Call EMS	C: Overall	C: Start	C: Depth	C: Rate	C: Position	C: Recoil	C: No flow time	AED	V: Rate	V: Vol.	Overall				
End-of-course	Cuijpers31	approach sequence:															
Jimenez-Fabrega32																			
Lanzas33																			
Pérez-Bailòn34																			
Yeung35																			
<3 mths	Cuijpers31	approach sequence:															
Lanzas33																			
6–12 months	Bohn30																			
Jimenez-Fabrega32																			
Lukas38																			
Yeung35																			
2 yrs	Bohn30																			
3 yrs	Bohn30																			
Lukas38																			
4 yrs	Bohn30																			
6 yrs	Lukas38																			
C)	
med student	
	Skills	Knowledge	Willingness	Confidence	
	Safety Check	Check response	Check breathing	Call EMS	C: Overall	C: Start	C: Depth	C: Rate	C: Position	C: Recoil	C: No flow time	AED	V: Rate	V: Vol.	Overall				
End-of-course	Cuijpers31	approach sequence:															
<3 mths	Cuijpers31	approach sequence:															
Dîrzu36																			
Haseneder37																			
6–12 months	Haseneder37																			

Peer-tutors compared to training led by HCP (n = 5) (Table 4A)

Four studies assessed overall skills at short-term28, 29, mid-term28, and long-term, 27 showing no significant differences between peer-led and expert led groups. However, one study reported significantly inferior outcomes for peer-led training (short- and mid-term assessments) for the parameters ‘check response and breathing’, ‘call EMS’, ‘compression depth’ and ‘compression recoil’.28

All four studies reported the assessment of chest compression rate and depth at the end-of-course as dichotomous data (% children failing or passing the test).28, 29 One study27 reported the percentage of children fulfilling ERC guideline recommendations, which was rated as ‘pass’. Homogeneity testing for compression rate showed significant heterogeneity (Q = 8.65, df = 3, p-value = 0.03). Data for compression depth showed sufficient homogeneity to calculate the effect size (Q = 0.45, df = 3, p-value = 0.93) which revealed an overall effect of z = −0.77 (p-value = 0.44). Forest plots are depicted in Fig. 2. Due to the small number of studies included in the metanalysis we did not perform a formal assessment of publication bias.40Fig. 2 Forest plot depicting size effect calculated with random-effects model for binary data (% students passing the skills test) for the outcomes compression depth (A) and compression rate (B) of the intervention group ‘peer-tutors’. Confidence interval for homogeneity testing with Cochrane’s Q-Test and for the metaanalysis was set at α = 0.05. Included references: Beck 201525, Sabihah 202028, Santomauro 201829, Damvall 2022.27

Knowledge and willingness to perform CPR was equivalent for those taught by peer-tutors and by HCPs for short- 28 to mid-term.26, 28

Schoolteacher-led training compared to training by HCPs (n = 7) (Table 4B)

In the five studies comparing schoolteacher led to expert/HCP led training, results were equivalent for all time points and for nearly all skills. 32, 33, 34 Only ‘ventilation volume’ was lower for training by schoolteachers after 2 years in two studies. 30, 35 However, ‘call EMS’, ‘compression depth’, ‘compression rate’, and ‘ventilation rate’ was found better after schoolteacher training. 30, 32, 33, 35 As ‘compression depth’ and ‘compression rate’ were reported with heterogenous outcomes (pass/fail, % correct, performance scores, and definite measurements), a meta-analysis did not appear reasonable. We did not consider further methods to adjust for the inconsistencies between studies.

Schoolteacher training yielded equivalent results to HCPs in three of the five studies for knowledge, willingness to perform CPR and confidence,30, 32, 34 but the other two studies showed HCPs achieved superior results.35, 36

Medical students compared to HCP-led training (n = 3) (Table 4C)

Results of the overall skills assessment were found to be better after training by medical students than by HCPs, for short- 31 and midterm. 31, 37 Regarding specific skills, the studies reported equivalence for early all skills, except for ‘use of defibrillators,’ where the medical students achieved better results than HCPs. Transfer of knowledge for mid- 37, 38 and long-term38 was more effective when schoolchildren were instructed by medical students. Self-confidence was reported as equivalent.

Discussion

Overall, this systematic review showed that for training resuscitation skills, the alternative teachers – peers,25, 26, 27, 28, 29 schoolteachers30, 31, 32, 33, 34, 35, 36 and medical students31, 37, 38, 41 – were equivalent to HCPs. Only in one study (with two publications) was the retention of one skill (‘ventilation volume’) lower in the intervention group.30, 35 Regarding the acquisition of CPR knowledge however, schoolteachers and medical students reached superior results.35, 36, 31, 32, 33

In the following section, we will discuss the three non-HCP groups in more detail.

Peer-tutors

The studies included reported that peer teachers achieved equivalent results to HCP instructors for skills, 25, 27, 28, 29 knowledge transfer26, 28 and confidence boost. 26 Peer training has already been shown effective for teenagers in health education, especially when talking about taboo topics. 42 A recent study showed that after CPR training, male teenagers were less willing to attempt resuscitation on women. 43 Such gender effects when performing CPR in real life have been reported as one factor lowering survival rates of females. 43, 44, 45 A survey of male adults reported that 34% feared sexual harassment charges. 46 Issues that can hinder resuscitative efforts might be better addressed with teens by peers than by HCPs. This aspect of training should be further assessed with an appropriate study design.

As a further point, it has been shown that teenagers as peer-tutors who taught health education topics (e.g., healthy nutrition) applied this knowledge in their daily life. 42 Likewise, peer-training by medical students has been shown to increase the tutors’ own resuscitation skills, confidence and willingness to initiate CPR. Whether this also applies to schoolchildren is also still unknown.

Studies25, 26, 27, 28, 29 included here reported heterogeneous preparatory educational strategies for peer-tutors. Peers had received education for between 3 h and 2 days, including either only knowledge and skills of CPR 26, 27, 28, 29 or additional didactic skills such as the Peyton’s four-step approach25 or instructions on providing feedback. 25 This heterogeneity between studies might explain the divergent results of the peer-taught CPR training. As one example, a study using same-aged peer-tutors reported worse skill acquisition (compared to HCPs) for some skills even after extensive training of the peer-tutors. 28 In contrast, another study25 intentionally selected peers who were two to three years older than their ‘trainees’ and achieved equivalent results compared to HCPs. However, whether older peers really achieve better results, remains to be determined by specifically designed studies.

Schoolteacher as trainers

In the studies of this review, training by schoolteachers 30, 31, 32, 33, 34, 35, 36 was overall equivalent 30, 31, 32, 33, 34, 35, 36 to HCP training. For some skills, teachers reached superior results (‘calling EMS’33, ‘compression rate30, 35 and depth35′, ‘overall judgement’32, 33), while ventilation skills after one year were inferior when taught by teachers30, 35. Regarding knowledge transfer, teachers were more effective for a variety of outcomes, 30, 32, 34, 35, 36 even for time points up to one-year post-intervention.30, 34, 35, 36

The included studies reported initial training of the schoolteachers to become CPR instructors. However, no information was available on whether these teachers were provided with refresher courses, similar to those for ERC-certified BLS instructors. 47 Both initial training and refresher courses are important supportive strategies as lack of confidence in their own CPR knowledge and skills has been reported as a relevant factor for lower willingness to teach CPR in schools. 15 It has been suggested to add CPR instructor training to the teacher training at universities. 12 The impact of subsequent refresher courses has not yet been studied.

Medical students

Our review indicates that medical students are a good alternative to HCP instructors. 31, 37, 38 Surprisingly, medical students showed superior results in transferring knowledge37, 38 and in the skills ‘using an AED’31 and ‘overall skill assessment’. 38 Previous studies have suggested that such training could be incorporated into undergraduate medical curricula considering that acting as a CPR instructor in schools improved medical students’ own CPR skills. 39, 48, 49 Involving medical students in school CPR training programmes was has also been proposed as part of a concept of creating ‘training cascades’, 50, 51 where medical students instruct schoolteachers who then select and train schoolchildren as peer-instructors to teach their classmates. Such a system could demonstrate that essential CPR skills can be acquired by anyone. In addition, university education could be directly linked to a service for the society. However, research is still needed to better understand the effective mechanisms of such cascades.

Overall, this systematic review shows that ‘Kids-Save-Lives’ trainings for schoolchildren does not appear dependent on HCPs as instructors. Schoolteachers have already been proposed by ILCOR and the European Resuscitation Council as equivalent alternatives. 12, 52 This systematic review confirms this recommendation and even suggests that schoolteachers could be the preferred option if given proper training opportunities. For easier implementation, we encourage the inclusion of CPR instructor training into teacher training at university. Such trainings could be held by medical students. Including peer-tutors could help to reach more schoolchildren.

Some important limitations need to be addressed. (1) The overall certainty of evidence was rated from ‘low’ to ‘very low’, even though only controlled studies were included. Reasons included risk of bias, imprecision, and inconsistency. (2) The heterogeneity of the studies included was significant, as the training strategies differed significantly, especially for knowledge transfer (lecture,25, 26, 29, 30, 31, 34, 35, 36, 37, 38 e-learning,27 video, 28, 29, 32, 34) as well as for study designs (randomized controlled trials, 25, 28, 31, 34 cluster-randomized controlled trials,32, 37, 38 non-randomized experimental studies26, 27, 29, 30, 33, 35, 36). Additional subgrouping of the studies according to short-term,25, 27, 28, 32, 33, 34 mid-term26, 27, 30, 31, 32, 34, 35, 36, 37, 38 and long-term-30, 35 retention further lowered the sample sizes. A further source of heterogeneity was the large variation in assessment tools, including individually created tools that had not been adequately validated. Even for rather objective skill assessments, some authors reported data retrieved from manikins27, 35, 30, 31 while others used individually created checklists.25, 28, 29, 31, 32, 33, 34 Analysis of more abstract outcomes, such as willingness to perform CPR26, 34 and confidence,30, 35, 38 was also performed based on individually-designed questionnaires, which again were often not validated. In addition, we did not find information on whether questionnaires had been adapted to the schoolchildren’s ages.

As a further limitation, publication bias is likely given that the investigators were interested in the topic.53 However, we did not formally assess publication bias as only a few studies could be included in the meta-analyses. Finally, the included studies were performed in Europe and two in Asia. Whether these findings can be transferred to other countries with different cultural and/or socioeconomic contexts cannot be answered with certainty.

Knowledge gaps and future research

Several open questions remain regarding teachers in ‘Kids-Save-Lives’ trainings. For peer-tutors, a small age gap between tutor and trainee may benefit schoolchildren, but this hypothesis requires further investigation. For both peer-tutors and schoolteachers, clearer information is needed about refresher courses, including the extent, content, and timing of such courses. Studies are also needed to evaluate combinations of peer-training and schoolteacher-led training, as well as ‘training cascades’ with medical students.

To allow for appropriate comparisons and meta-analyses, validated age-adapted training programmes, questionnaires, and skills-assessments need to be standardized. Therefore, uniform reporting guidelines for educational studies in resuscitation are urgently needed.

Conclusions

This systematic review analysed studies comparing different alternative training personnel (peer-tutors, schoolteachers, or medical students) with HCPs as instructors. Overall, the studies showed equivalent learning outcomes for CPR skills and knowledge up to one year, and some aspects of knowledge acquisition were even superior after training by non-HCPs. For peer training, a small age gap between peers and the trainees trained might be advisable. Based on these results, future studies should address whether involving non-HCP instructors makes these programs more cost-effective and easier to integrate into school curricula, as well as examining which type of refresher courses are most effective for various non-HCP instructor groups. This would potentially increase the overall effectiveness of Kids-Save-Lives programmes.

Ethical approval

Not applicable.

Funding

None (academic study).

CRediT authorship contribution statement

A. Mollo: Writing – original draft, Software, Project administration, Methodology, Investigation, Formal analysis, Data curation. S. Beck: Writing – review & editing, Investigation, Formal analysis, Data curation. A. Degel: Writing – review & editing, Investigation, Formal analysis. R. Greif: Writing – review & editing, Methodology, Investigation, Formal analysis. J. Breckwoldt: Writing – review & editing, Writing – original draft, Validation, Supervision, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: AM: None to declare. SB: declared an intellectual conflict of interest and was excluded from data extraction and Risk of Bias assessment of the studies she co-authored.25, 39 AD: None to declare. RG: European Resuscitation Council Director of Guidelines and ILCOR, ILCOR Task Force Chair Education, Implementation and Teams. RG is an Editorial Board member of ‘Resuscitation Plus’. JB: Member of the ILCOR EIT Task Force (Education, Implementation and Teams); member of the ERC Science and Education Committee /SEC IES; member of the writing group for the ERC Guidelines 2025 (Chapter Education).].

Appendix A Supplementary material

The following are the Supplementary data to this article:Supplementary Data 1

Acknowledgements

We thank Jacqueline Huber, Information Specialist from the University of Zurich, Switzerland, for her work generating the search strategy and conducting the search.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.resplu.2024.100755.
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