Enhancing Global Understanding of Cardiopulmonary Resuscitation (CPR) Proficiency Among Medical Students and Practitioners

Enhancing Global Understanding of Cardiopulmonary Resuscitation (CPR) Proficiency Among Medical Students and Practitioners | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enhancing Global Understanding of Cardiopulmonary Resuscitation (CPR) Proficiency Among Medical Students and Practitioners Mohamedelmusafa Yahya, Mohammed Hamad, Aziza Abdalmahmoud, Ibrahim Dafallah, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5986888/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Cardiac arrest remains a critical global health challenge with low survival rates. This study aims to assess the proficiency of cardiopulmonary resuscitation (CPR) among medical students and practitioners across multiple countries, identifying knowledge gaps and barriers to effective practice. Methods: A descriptive, cross-sectional online survey was conducted in April 2024, targeting medical students and healthcare practitioners worldwide. A total of 3,084 participants from 44 countries completed the survey, which evaluated CPR knowledge, attitudes, practices, and perceived barriers. Statistical analysis was performed using SPSS v28.0.0. Results: Overall CPR knowledge among participants was only 44%, with significant deficiencies in critical areas such as chest compression rates for adults (20%) and infants (26%). Notably, 63% cited lack of access to training as a major barrier, while 64% emphasized the necessity for regular CPR training for healthcare providers. Positive attitudes towards integrating CPR training into educational curricula were observed, with 58% supporting free community training initiatives. Conclusion: The study highlights significant gaps in CPR knowledge and practice among medical students and practitioners, underscoring the need for enhanced training programs. Implementing regular CPR education and addressing identified barriers can improve preparedness and outcomes in cardiac arrest situations globally. Cardiopulmonary resuscitation CPR proficiency medical education healthcare training global health knowledge gaps Introduction Cardiac arrest is a life-threatening emergency with significantly low survival rates. It is a sudden and unexpected cessation of blood circulation following the failure of the heart to pump effectively [ 1 ]. According to the American Heart Association's Heart and Stroke Statistics − 2024 Update, cardiac arrest remains a substantial public health crisis with more than 356,000 out-of-hospital cardiac arrests (OHCA) annually in the U.S. (nearly 1,000 people each day), and about 90% of them are fatal. There are several challenges in understanding the distribution and determinants of cardiac arrest. Despite being a global burden for many years, there are no benchmarks for monitoring the incidence and outcomes of cardiac arrest [ 2 ]. Cardiopulmonary resuscitation (CPR) is a fundamental technique within the Basic Life Support (BLS) protocol. It is a collection of interventions consisting of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest [ 3 , 4 ]. Although the survival rate is poor for patients with cardiac arrest, early and effective CPR has been found to increase the survival rate, neurological outcomes, and post-cardiac arrest quality of life [ 5 ]. Every minute without CPR and defibrillation reduces the victim's chance of survival from cardiac arrest by 7–10% [ 6 ]. Hence, prompt initiation of CPR undoubtedly saves lives. It is important that effective and expeditious resuscitation is by theoretical knowledge and repeated practice [ 7 ]. Recent studies have demonstrated suboptimal and inadequate CPR knowledge and practice, with some studies reporting a high level of awareness and positive attitudes towards the implementation of CPR training among medical students and junior doctors [ 8 – 11 ]. This lack of knowledge and inadequate practice regarding handling these time-critical situations can strongly influence the ultimate outcome for a patient experiencing cardiac arrest. By enhancing CPR understanding and proficiency, we can be a step closer to achieving a lasting superiority of theoretical and practical skills, which is a necessary combination for optimal CPR performance [ 10 ]. While many studies have focused on CPR knowledge, attitude, and practice among medical students and practitioners in specific countries, there is a lack globally-based studies regarding CPR proficiency. Therefore, by conducting this research we aim to gain insight into the current situation of CPR knowledge, skills, and barriers on a global scale to guide future education and training efforts that will enhance healthcare delivery to cardiac arrest patients worldwide. Methodology 2.1. Study Design This study employed a descriptive, cross-sectional design using an online survey to gather data from a multinational sample of medical students and practitioners. The cross-sectional nature of the study provides a snapshot of CPR knowledge, attitudes, practices, and perceived barriers during April 2024. Given the global scope of the study and the feasibility constraints of accessing diverse populations internationally, a convenience sampling approach was adopted. The inclusion criterion comprised all medical students and healthcare practitioners (which includes physicians, nurses, paramedics, and other healthcare professionals involved in resuscitation), irrespective of geographic location. The study excluded individuals who were present in the online social media forums where the survey was shared, those who were not active online during the data collection period, and those who opted not to participate in the survey. The total number of medical students and health workers worldwide is unknown therefore, The sample size for an unknown population was calculated using the formula n=z2 P(1-P)/d2 [12]. With a 90% confidence interval, 50% response distribution and a 0.05 margin of error, a minimum sample size of 385 participants was determined to adequately represent the population. 2.2. Data Collection An online self-administered questionnaire was developed by literature review and input from faculty members of the Alzaiem Alazhari University Faculty of Medicine. The questionnaire was structured into four sections: (1) Knowledge: Nine multiple-choice questions assessing CPR knowledge; (2) Attitude: Thirteen 5-point Likert-scale questions (e.g., strongly disagree to strongly agree) evaluating attitudes towards CPR and training; (3) Practice: Questions on CPR practice frequency, experience with real patients and mannequins, use of automated external defibrillators (AEDs), and review of guidelines; (4) Barriers: Sixteen 5-point Likert-scale questions explored perceived obstacles to CPR training and implementation. The target population for this study was medical students and practitioners (including physicians, nurses, paramedics, and other healthcare professionals involved in resuscitation) from any country. Data collection was performed using Google Forms. The survey link was shared through professional and personal networks and across the social media platforms mentioned above. Regular reminders were posted during the data collection period to encourage participation. While participants' IP addresses were not collected to preserve anonymity, Google Forms was restricted to one response per IP address. 2.3. Data Management and Statistical Analysis Responses were collected and stored with access restricted to the research team. Data were then analyzed using Statistical Package for Social Sciences (SPSS) v28.0.0. Descriptive statistics, including frequencies and percentages, were calculated to summarize responses. Likert-scales were used to analyze participant attitude and perceived barriers by assigning numerical values (e.g., 1 to 5 for strongly disagree to strongly agree) and summarizing these as frequencies and percentages for each category. Chi-squared tests were used to compare categorical variables. 2.4. Ethical Approval Ethical approval for this study was obtained from the Research and Ethics Committee of Alzaim AL-Azhari University Informed consent was obtained from all participants. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines were followed to ensure comprehensive reporting. [14] Results A total of 3,084 participants responded to the survey. The average age of the respondents was 26.5 years (SD+_ 5.1). The 1847 (59.9%), were postgraduates and practitioners, and 1237 (40.1%) were medical students. Approximately three-fifths, 1833 (59.8%), were females and 1228 (39.8) were males. A vast majority of the study participants 2590 (84%) lived in urban areas while 494 (16%) lived in rural areas. Participants represented 44 countries, with the majority, 2,733 (72%) being from Sudan (Table 2). Detailed demographic data is provided in Table 1. Knowledge The overall CPR knowledge among participants was 44%, highlighting inadequate awareness. A significant gap was noted in identifying the correct chest compression rate for adults, with only 20% answering accurately, while 43% mistakenly identified it as 60 compressions per minute. Knowledge deficiencies were more pronounced in infant-specific CPR. Only 26% correctly identified the chest compression rate for infants, and similarly, only 31% answered questions regarding the depth of compressions for infants correctly. Misconceptions were common, such as 54.3% identifying the compression depth as 1 inch (2.5 cm). Knowledge about adult-specific CPR was higher, particularly in hand placement for chest compressions (69%) and the compression-ventilation ratio for single rescuers (66%) (Table 3, Table 4). Given the high number of participants from Sudan, a separate analysis was conducted for participants from other countries, revealing a total knowledge percentage of 45%. This group showed slightly better understanding of the adult chest compression rate (26%) and infant chest compression rate (20%), as well as compression depth (50% for adults, 36% for infants). Knowledge of adequate compression was at 50%. However, lower scores were noted for infant compression-ventilation ratios (36%) and for recognizing signs of effective ventilation (43%) (Table 3). (Table 4) Responses of healthcare workers' to CPR knowledge questions: Attitude Nearly half of the participants (1,475; 48%) believed CPR training should be integrated into the school curriculum as part of civil responsibility. Additionally, 1,239 participants (40%) suggested that witnessing cardiac arrest should come with a legal mandate to perform CPR. A majority of participants (1,785; 58%) emphasized the need to make BLS and CPR training more accessible in the community. Similarly, 1,794 participants (58%) felt CPR training should be free of charge to the public. Awareness campaigns about the importance of CPR training were supported by 1,753 participants (57%). Some participants (1,113; 36%) suggested making CPR certification mandatory for obtaining a driving license. Additionally, 1,720 participants (56%) believed CPR training should become a standard component of workplace safety programs. The importance of regular BLS and CPR training for healthcare providers was highlighted by 1,967 participants (64%). Practicing these skills regularly to improve survival rates in cardiac arrest cases was recommended by 1,777 participants (58%). Finally, 1,480 participants (48%) proposed that employers organize regular CPR and BLS training sessions to ensure employees maintain BLS certification validity. Practice A significant number of participants, 1,447 (47%), rarely practice CPR or have never practiced CPR skills, whereas 644 (21%) practice CPR on a monthly basis. When it comes to real-life application, 1,254 (41%) of the participants have performed CPR on real patients multiple times, while 757 (25%) have never performed CPR before. About one-third, totaling 1,067 (35%), occasionally update their knowledge in CPR, BLS, ACLS, and ATLS by reviewing online resources. Meanwhile, 861 (28%) rarely update their knowledge, 598 (19.4%) never update their skills, and only 558 (18%) consistently attend courses and workshops to refresh their knowledge. A majority, 1,411 (46%), have never been trained to use or apply an AED in life-threatening situations. Out of the remaining participants, 961 (31%) have been trained but have not used it, 501 (16%) have used AEDs successfully, while 211 (7%) attempted AEDs without success. Furthermore, 1,363 (44%) rarely or never review the guidelines for BLS and CPR, with only 730 (24%) revisiting the guidelines annually. Regarding confidence, 989 (32%) participants feel moderately confident in recognizing cardiac arrest and initiating proper CPR measures, while 863 (28%) feel very confident, and 550 (18%) feel no confidence at all. Additionally, 1,136 (37%) participants have never attended debriefing sessions after a resuscitation event, compared to only 410 (13%) who always participate in such sessions. When it comes to teaching courses such as BLS, CPR, or ATLS, 1,300 (42.2%) of participants stated they have never taught these courses and feel unqualified to instruct. In contrast, 646 (21%) have not taught them but believe they are qualified to do so, while only 432 (14%) frequently teach courses in these areas. Barriers A majority of participants, 1,954 (63%), believe that a lack of access to BLS training creates significant obstacles and negatively impacts CPR outcomes. Similarly, 1,286 (42%) think that limited access to CPR-related materials and resources hinders skill retention, while another 1,286 (42%) also believe that restricted access to CPR tools, such as AEDs, reduces the effectiveness of resuscitation efforts. Additionally, 1,238 (40%) participants feel that inadequate employer support to promote and maintain CPR training diminishes motivation. A larger group, 1,488 (48%), identified limited availability of CPR courses in their area as a key factor restricting skills development. Cultural and religious considerations were cited by 1,010 (33%) as discouraging individuals from participating in CPR and BLS practice. Nearly half of the participants, 1,392 (45%), believe that a limited understanding of the importance of early defibrillation slows bystander response rates to cardiac arrest events. Similarly, 2,086 (47%) think that low public awareness about the vital role of CPR and BLS contributes to poor bystander response rates. Fear of legal liability deters 1,115 (36%) from performing CPR in public scenarios, and 1,572 (35%) pointed to hesitancy due to a lack of confidence in their skills as another important barrier to intervening during emergencies. A concern about potentially injuring patients prevents 1,102 (36%) from initiating CPR or resuscitation efforts, while 1,105 (36%) feel that the stigma surrounding unsuccessful attempts discourages involvement in CPR or ACLS training. In addition, 1,138 (37%) believe that the lack of recognition for individuals trained in CPR or ACLS limits their motivation to improve and develop their skills. Geographic isolation which restricts access to emergency services and training was noted as an issue by 1,462 (47%), whereas 598 (20%) participants identified language barriers as a significant obstacle to receiving proper CPR and ACLS training. Discussion The quality of performing Cardiopulmonary Resuscitation (CPR) is directly linked to survival rates, particularly when the time between cardiac arrest and the first defibrillator shock is minimized [1-5]. Immediate bystander CPR remains the most critical factor in improving outcomes for cardiac arrest patients, as it bridges the gap until professional medical help arrives. [14] Our study identifies large gaps in CPR knowledge, attitudes, and practices, similar to other studies, indicating the need for improved training and education globally. Findings from this study revealed that overall CPR knowledge among participants was only 44%, with notable deficiencies in critical areas. For instance, only 20% of respondents correctly identified the recommended chest compression rate for adults, and just 26% recognized the correct compression rate for infants. Knowledge of infant-specific CPR—such as compression depth (31%) and ventilation ratios (48%) was also low. The lower proficiency in Infant-specific CPR when compared to Adult-specific CPR is similar to findings in earlier studies [7]. This discrepancy is likely due to the predominant focus on Adult-specific CPR during foundational training. Only 20% of respondents could correctly identify the recommended chest compression rate for adults, and only 45% recognized the signs of adequate compression depth. These results align with previous studies; a 2017 study conducted in Nigeria revealed a significant lack of CPR knowledge among healthcare providers - awareness regarding the use of defibrillators scored the lowest in both knowledge and practice assessments. [1] Deficiencies in CPR knowledge have been consistently reported among doctors and medical students from other developing countries like Ecuador, Egypt, Ethiopia and Nigeria [7-9, 11]. Participants from outside Sudan showed slightly better overall knowledge scores (45%) compared to 44% for all participants; yet deficiencies in this group were prominent in infant-specific CPR (36%) and recognizing adequate ventilation (43%). Many of our participants indicated that they rarely practice or update their CPR skills, while a majority admitted never practicing CPR at all. A previously conducted study revealed significant deficits in CPR practice, with limited retraining sessions [10]. Our study also showed that most healthcare providers do not review BLS and CPR guidelines regularly and very few review these guidelines annually or biannually. Records showed that most respondents felt unqualified to teach CPR and other life-support skills such as BLS and Advanced Trauma Life Support (ATLS). A study conducted in Nigerian medical schools found high levels of CPR knowledge and AED identification among students. However, most participants had never performed CPR in real-life scenarios despite undergoing training [8]. Our study includes medical students, who may be expected to have a lower level of knowledge about CPR, as indicated by a study conducted in Saudi Arabia.It could be the fact that our study has medical students, a lower level of knowledge about CPR may be expected as reported in a study in Saudi Arabia. [15] A Lancet study argued that current CPR guidelines are mostly designed for high resource contexts making its effective learning and implementation be difficult in low resource health systems due to the lack of health workers and equipment. [16] A global meta analysis on out of hospital cardiac arrest found higher treatment rates in North America and Europe [17]. Regardless, all these knowledge gaps and misconceptions highlight the need for global collaboration to improve in CPR training and education in both high and limited resource contexts to develop versatile and competent health workers [18]. Despite the knowledge gaps, participants demonstrated generally positive attitudes toward CPR training. A majority (64%) believed that healthcare providers should receive regular CPR training, while 58% advocated for free CPR training for the public. Nearly half (48%) suggested integrating CPR education into school curricula to promote civic responsibility, and 56% recommended making CPR training a mandatory component of workplace safety programs. Previous studies reflected a strong willingness to improve CPR education and accessibility however this knowledge was not consistently matched by adequate skills and practice. [8] This is unlike another study performed in Ethiopia where two-thirds of the participants had poor knowledge about CPR and more than half of the participants had unfavourable attitudes towards CPR showing a stronger relationship between knowledge and attitudes at extended levels [17, 19]. The majority of respondents expressed confidence in their ability to perform CPR in emergency situations. Furthermore, most agreed that CPR training should be included in school curricula. The records indicate that CPR training should be viewed as a civic responsibility and play a critical role in workplace safety. Respondents also believe that employers and drivers should provide ongoing interactive sessions for recertification and maintenance of CPR certification. Many respondents said that making CPR training affordable or free for the public, along with awareness campaigns, would enhance understanding of the importance of CPR. Our study also showed some fears and misconceptions regarding CPR. For example, 36% of participants reported fear of causing injury during CPR, and 35.8% cited the stigma associated with unsuccessful resuscitation attempts as a deterrent. Additionally, fear of legal liability discouraged 36% from intervening in public settings. It is notable that ethical and legal aspects of CPR need to be clarified to health workers including consent and legal liability as per country laws to improve health workers confidence in performing CPR and ensuring quick resuscitation. [20, 21] Lack of access to regular BLS training sessions was reported by 63% of participants. Geographic isolation was considered a barrier by 47% of respondents which can be interpreted as further limited access to BLS training. Additionally, 42% pointed to limited availability of CPR materials and resources as a significant barrier, 20% mentioned language barriers to learning CPR, while 33% cited cultural and religious considerations as discouraging factors. Other barriers included fear of legal liability (36%), fear of causing injury (36%), and a perceived lack of recognition or appreciation for trained individuals (37%). In the literature, barriers to effective CPR performance were frequently attributed to insufficient practice, a lack of access to BLS training, and inadequate support from colleagues [9]. Enhancing CPR training modalities to account for these barriers could involve hands-on exercises and peer-learning approaches. Limited access to training and bystander CPR tools, particularly in geographically isolated areas, further exacerbates this issue [11]. Other challenges include language barriers, religious beliefs, and the unaffordable costs of some CPR training programs [7]. A lack of confidence in BLS skills was also identified as a major barrier to performing CPR, with approximately 35% of healthcare providers expressing hesitation due to fear of causing injury [8]. Such fears can lead to a stigma around CPR if attempts are unsuccessful. Nearly half of the participants (47%) rarely or never practice their CPR skills. Additionally, 28% rarely updated their knowledge, and only 18% regularly attended workshops or courses to refresh their skills. Studies show that CPR proficiency declines rapidly without reinforcement, often within months. Over 25% of participants had never performed CPR on a real patient, further highlighting the gap between theoretical knowledge and practical application. Frequent retraining of healthcare providers is vital to improving CPR outcomes—this should occur every two years, at least to refresh less common concepts of CPR [3].A study conducted in Malaysia to assess the CPR resuscitation among COVID-19 patients found low standards of practice in ventilation techniques, use of supraglottic devices, and intubation barriers despite good performance and knowledge in other areas. [22] A study found that short distributed CPR training on a mannequin is effective in improving CPR performance, with a month being the best spacing between CPR training sessions. [23, 24] This aligns with findings that highlight how infrequent training leads to rapid skill degradation, with CPR proficiency declining within months of training if not regularly reinforced. [24] Moreover feedback through CPR feedback technology and CPR coaches can improve CPR quality in resuscitation teams [25]. A significant proportion of participants (46%) had never been trained to use an AED, and only 16% reported successfully using one in a real-life situation. A study conducted among the general public found increased knowledge about AEDs improved public perceptions about these devices and their importance in increasing survivability [26]. Another study found strong correlation between knowledge about AEDs and willingness to employ these devices in resuscitation [27]. Limitations Due to the convenience sampling methods adopted for data collection, data may not accurately represent the global population. Furthermore most studies in this field are general and require more in depth analysis of specific attitudes and practices related to CPR. Conclusion This study revealed that while attitudes toward CPR were generally positive, gaps in knowledge, training and lack of hands-on practice, and updated guidelines hinder effective CPR performance. Medical schools and public health authorities should work in tandem to address barriers to emergency resuscitation. Regular retraining, integration of CPR education into academic and workplace programs, and increasing public awareness about CPR can enhance knowledge, attitudes and practical application of CPR. Declarations Ethical approval and consent to participate Ethical approval of the study was obtained from the IRB of Alzaiem Alazhari University. Informed written consent from each participant was guaranteed before partaking in the study and confidentiality of the participants was secured. The study was carried out according to the relevant ethical guidelines and regulations. Consent for publication Not applicable Availability of data and material The datasets used and analyzed during the current study are available and can be accessed through the link: https://osf.io/87su6/?view_only=100ae01aef32498eacc2327606dfe81f. The data are intended for publication as an online data supplement Competing interests The authors declare that they have no competing interests. Funding The authors received no funding for this work. Authors contributions All authors made a significant contribution to the study reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. Clinical trial number: Not applicable. References Aliyu I, Michael G, Ibrahim H, Ibrahim Z, Idris U, Zubayr B, et al. The practice of cardiopulmonary resuscitation among health care providers in a tertiary health center in a semi-urban setting. J Acute Dis. 2019;8(4):160. 10.4103/2221-6189.263709 . Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, et al. Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association. Circulation. 2022;145(8). 10.1161/CIR.0000000000001052 . 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AlRadini FA, Sabbagh AY, Alamri FA, Almuzaini Y, Alsofayan YM, Alahmari AA, et al. Application of automated external defibrillators among the public: a cross-sectional study in Saudi Arabia. Int J Gen Med. 2023;16:5089–96. Dafallah I. Enhancing global understanding of cardiopulmonary resuscitation proficiency. OSF; 2024 [updated 2024-11-26]. Available from: https://osf.io/87su6/?view_only=100ae01aef32498eacc2327606dfe81f Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5986888","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":415185636,"identity":"f412e917-949a-4707-b37e-d775e42923af","order_by":0,"name":"Mohamedelmusafa Yahya","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Mohamedelmusafa","middleName":"","lastName":"Yahya","suffix":""},{"id":415185637,"identity":"ad13d9c3-9d1e-4a64-90ec-163762699f30","order_by":1,"name":"Mohammed Hamad","email":"","orcid":"","institution":"Alzaiem Alazhari 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Dafallah","email":"data:image/png;base64,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","orcid":"","institution":"Alzaiem Alazhari University","correspondingAuthor":true,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Dafallah","suffix":""},{"id":415185640,"identity":"7a3b55b2-f8e8-46da-a4c5-dc4901b70c93","order_by":4,"name":"Yousif Omer Elgaili","email":"","orcid":"","institution":"Alzaiem Alazhari University","correspondingAuthor":false,"prefix":"","firstName":"Yousif","middleName":"Omer","lastName":"Elgaili","suffix":""},{"id":415185641,"identity":"59b710a4-a6ae-4be0-8761-c2e922a2f437","order_by":5,"name":"Kalthoum Yahia Salih","email":"","orcid":"","institution":"University of Science and Technology Omdurman","correspondingAuthor":false,"prefix":"","firstName":"Kalthoum","middleName":"Yahia","lastName":"Salih","suffix":""},{"id":415185642,"identity":"e6b22fca-c734-4e0f-aa8d-12f1e5d0c860","order_by":6,"name":"Rayan Osama","email":"","orcid":"","institution":"University of Bahri","correspondingAuthor":false,"prefix":"","firstName":"Rayan","middleName":"","lastName":"Osama","suffix":""},{"id":415185643,"identity":"07ea870f-e976-455e-b34d-a2d7d958dfa2","order_by":7,"name":"Ola Yaser","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Ola","middleName":"","lastName":"Yaser","suffix":""},{"id":415185644,"identity":"5049d57d-20ef-46ff-a822-70d5d10b7695","order_by":8,"name":"Rayan Abdalla","email":"","orcid":"","institution":"Alzaiem Alazhari University","correspondingAuthor":false,"prefix":"","firstName":"Rayan","middleName":"","lastName":"Abdalla","suffix":""},{"id":415185645,"identity":"27c52601-dc50-4f66-8ab5-9fb6fc0e6fc8","order_by":9,"name":"Leina Elfatih","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Leina","middleName":"","lastName":"Elfatih","suffix":""}],"badges":[],"createdAt":"2025-02-08 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12:09:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":400657,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5986888/v1/97902e9e-0364-4190-a494-b4f1ad0ba22f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhancing Global Understanding of Cardiopulmonary Resuscitation (CPR) Proficiency Among Medical Students and Practitioners","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCardiac arrest is a life-threatening emergency with significantly low survival rates. It is a sudden and unexpected cessation of blood circulation following the failure of the heart to pump effectively [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. According to the American Heart Association's Heart and Stroke Statistics \u0026minus;\u0026thinsp;2024 Update, cardiac arrest remains a substantial public health crisis with more than 356,000 out-of-hospital cardiac arrests (OHCA) annually in the U.S. (nearly 1,000 people each day), and about 90% of them are fatal. There are several challenges in understanding the distribution and determinants of cardiac arrest. Despite being a global burden for many years, there are no benchmarks for monitoring the incidence and outcomes of cardiac arrest [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCardiopulmonary resuscitation (CPR) is a fundamental technique within the Basic Life Support (BLS) protocol. It is a collection of interventions consisting of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although the survival rate is poor for patients with cardiac arrest, early and effective CPR has been found to increase the survival rate, neurological outcomes, and post-cardiac arrest quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Every minute without CPR and defibrillation reduces the victim's chance of survival from cardiac arrest by 7\u0026ndash;10% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Hence, prompt initiation of CPR undoubtedly saves lives. It is important that effective and expeditious resuscitation is by theoretical knowledge and repeated practice [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent studies have demonstrated suboptimal and inadequate CPR knowledge and practice, with some studies reporting a high level of awareness and positive attitudes towards the implementation of CPR training among medical students and junior doctors [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This lack of knowledge and inadequate practice regarding handling these time-critical situations can strongly influence the ultimate outcome for a patient experiencing cardiac arrest. By enhancing CPR understanding and proficiency, we can be a step closer to achieving a lasting superiority of theoretical and practical skills, which is a necessary combination for optimal CPR performance [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile many studies have focused on CPR knowledge, attitude, and practice among medical students and practitioners in specific countries, there is a lack globally-based studies regarding CPR proficiency. Therefore, by conducting this research we aim to gain insight into the current situation of CPR knowledge, skills, and barriers on a global scale to guide future education and training efforts that will enhance healthcare delivery to cardiac arrest patients worldwide.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e2.1. Study Design\u003cbr\u003e\u0026nbsp;This study employed a descriptive, cross-sectional design using an online survey to gather data from a multinational sample of medical students and practitioners. The cross-sectional nature of the study provides a snapshot of CPR knowledge, attitudes, practices, and perceived barriers during April 2024. Given the global scope of the study and the feasibility constraints of accessing diverse populations internationally, a convenience sampling approach was adopted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe inclusion criterion comprised all medical students and healthcare practitioners (which includes physicians, nurses, paramedics, and other healthcare professionals involved in resuscitation), irrespective of geographic location. The study excluded individuals who were present in the online social media forums where the survey was shared, those who were not active online during the data collection period, and those who opted not to participate in the survey.\u003c/p\u003e\n\u003cp\u003eThe total number of medical students and health workers worldwide is unknown therefore, The sample size for an unknown population was calculated using the formula \u0026nbsp;n=z2 P(1-P)/d2 [12]. With a 90% confidence interval, 50% response distribution and a 0.05 margin of error, a minimum sample size of 385 participants was determined to adequately represent the population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u0026nbsp;2.2. Data Collection\u003c/p\u003e\n\u003cp\u003eAn online self-administered questionnaire was developed by literature review and input from faculty members of the Alzaiem Alazhari University Faculty of Medicine. The questionnaire was structured into four sections: (1) Knowledge: Nine multiple-choice questions assessing CPR knowledge; (2) Attitude: Thirteen 5-point Likert-scale questions (e.g., strongly disagree to strongly agree) evaluating attitudes towards CPR and training; (3) Practice: Questions on CPR practice frequency, experience with real patients and mannequins, use of automated external defibrillators (AEDs), and review of guidelines; (4) Barriers: Sixteen 5-point Likert-scale questions explored perceived obstacles to CPR training and implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe target population for this study was medical students and practitioners (including physicians, nurses, paramedics, and other healthcare professionals involved in resuscitation) from any country. Data collection was performed using Google Forms. The survey link was shared through professional and personal networks and across the social media platforms mentioned above. Regular reminders were posted during the data collection period to encourage participation. While participants' IP addresses were not collected to preserve anonymity, Google Forms was restricted to one response per IP address.\u003c/p\u003e\n\u003cp\u003e2.3. Data Management and Statistical Analysis\u003c/p\u003e\n\u003cp\u003eResponses were collected and stored with access restricted to the research team. Data were then analyzed using Statistical Package for Social Sciences (SPSS) v28.0.0. Descriptive statistics, including frequencies and percentages, were calculated to summarize responses. Likert-scales were used to analyze participant attitude and perceived barriers by assigning numerical values (e.g., 1 to 5 for strongly disagree to strongly agree) and summarizing these as frequencies and percentages for each category. Chi-squared tests were used to compare categorical variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.4. Ethical Approval\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Research and Ethics Committee of Alzaim AL-Azhari University Informed consent was obtained from all participants. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines were followed to ensure comprehensive reporting. [14]\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u0026nbsp;A total of 3,084 participants responded to the survey. The average age of the respondents was 26.5 years (SD+_ 5.1). The 1847 (59.9%), were postgraduates and practitioners, and 1237 (40.1%) were medical students. Approximately three-fifths, 1833 (59.8%), were females and 1228 (39.8) were males. \u0026nbsp;A vast majority of the study participants \u0026nbsp;2590 (84%) lived in urban areas while 494 (16%) lived in rural areas. Participants represented 44 countries, with the majority, 2,733 (72%) being from Sudan (Table 2). Detailed demographic data is provided in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eKnowledge\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall CPR knowledge among participants was 44%, highlighting inadequate awareness. A significant gap was noted in identifying the correct chest compression rate for adults, with only 20% answering accurately, while 43% mistakenly identified it as 60 compressions per minute. Knowledge deficiencies were more pronounced in infant-specific CPR. Only 26% correctly identified the chest compression rate for infants, and similarly, only 31% answered questions regarding the depth of compressions for infants correctly. Misconceptions were common, such as 54.3% identifying the compression depth as 1 inch (2.5 cm).\u003c/p\u003e\n\u003cp\u003eKnowledge about adult-specific CPR was higher, particularly in hand placement for chest compressions (69%) and the compression-ventilation ratio for single rescuers (66%) (Table 3, Table 4).\u003c/p\u003e\n\u003cp\u003eGiven the high number of participants from Sudan, a separate analysis was conducted for participants from other countries, revealing a total knowledge percentage of 45%. This group showed slightly better understanding of the adult chest compression rate (26%) and infant chest compression rate (20%), as well as compression depth (50% for adults, 36% for infants). Knowledge of adequate compression was at 50%. However, lower scores were noted for infant compression-ventilation ratios (36%) and for recognizing signs of effective ventilation (43%) (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Table 4) Responses of healthcare workers\u0026apos; to CPR knowledge questions:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAttitude\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNearly half of the participants (1,475; 48%) believed CPR training should be integrated into the school curriculum as part of civil responsibility. Additionally, 1,239 participants (40%) suggested that witnessing cardiac arrest should come with a legal mandate to perform CPR.\u003c/p\u003e\n\u003cp\u003eA majority of participants (1,785; 58%) emphasized the need to make BLS and CPR training more accessible in the community. Similarly, 1,794 participants (58%) felt CPR training should be free of charge to the public. Awareness campaigns about the importance of CPR training were supported by 1,753 participants (57%).\u003c/p\u003e\n\u003cp\u003eSome participants (1,113; 36%) suggested making CPR certification mandatory for obtaining a driving license. Additionally, 1,720 participants (56%) believed CPR training should become a standard component of workplace safety programs.\u003c/p\u003e\n\u003cp\u003eThe importance of regular BLS and CPR training for healthcare providers was highlighted by 1,967 participants (64%). Practicing these skills regularly to improve survival rates in cardiac arrest cases was recommended by 1,777 participants (58%). Finally, 1,480 participants (48%) proposed that employers organize regular CPR and BLS training sessions to ensure employees maintain BLS certification validity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003ePractice\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA significant number of participants, 1,447 (47%), rarely practice CPR or have never practiced CPR skills, whereas 644 (21%) practice CPR on a monthly basis.\u003c/p\u003e\n\u003cp\u003eWhen it comes to real-life application, 1,254 (41%) of the participants have performed CPR on real patients multiple times, while 757 (25%) have never performed CPR before. About one-third, totaling 1,067 (35%), occasionally update their knowledge in CPR, BLS, ACLS, and ATLS by reviewing online resources. Meanwhile, 861 (28%) rarely update their knowledge, 598 (19.4%) never update their skills, and only 558 (18%) consistently attend courses and workshops to refresh their knowledge.\u003c/p\u003e\n\u003cp\u003eA majority, 1,411 (46%), have never been trained to use or apply an AED in life-threatening situations. Out of the remaining participants, 961 (31%) have been trained but have not used it, 501 (16%) have used AEDs successfully, while 211 (7%) attempted AEDs without success. Furthermore, 1,363 (44%) rarely or never review the guidelines for BLS and CPR, with only 730 (24%) revisiting the guidelines annually.\u003c/p\u003e\n\u003cp\u003eRegarding confidence, 989 (32%) participants feel moderately confident in recognizing cardiac arrest and initiating proper CPR measures, while 863 (28%) feel very confident, and 550 (18%) feel no confidence at all. Additionally, 1,136 (37%) participants have never attended debriefing sessions after a resuscitation event, compared to only 410 (13%) who always participate in such sessions.\u003c/p\u003e\n\u003cp\u003eWhen it comes to teaching courses such as BLS, CPR, or ATLS, 1,300 (42.2%) of participants stated they have never taught these courses and feel unqualified to instruct. In contrast, 646 (21%) have not taught them but believe they are qualified to do so, while only 432 (14%) frequently teach courses in these areas.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eBarriers\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA majority of participants, 1,954 (63%), believe that a lack of access to BLS training creates significant obstacles and negatively impacts CPR outcomes. Similarly, 1,286 (42%) think that limited access to CPR-related materials and resources hinders skill retention, while another 1,286 (42%) also believe that restricted access to CPR tools, such as AEDs, reduces the effectiveness of resuscitation efforts.\u003c/p\u003e\n\u003cp\u003eAdditionally, 1,238 (40%) participants feel that inadequate employer support to promote and maintain CPR training diminishes motivation. A larger group, 1,488 (48%), identified limited availability of CPR courses in their area as a key factor restricting skills development. Cultural and religious considerations were cited by 1,010 (33%) as discouraging individuals from participating in CPR and BLS practice.\u003c/p\u003e\n\u003cp\u003eNearly half of the participants, 1,392 (45%), believe that a limited understanding of the importance of early defibrillation slows bystander response rates to cardiac arrest events. Similarly, 2,086 (47%) think that low public awareness about the vital role of CPR and BLS contributes to poor bystander response rates. Fear of legal liability deters 1,115 (36%) from performing CPR in public scenarios, and 1,572 (35%) pointed to hesitancy due to a lack of confidence in their skills as another important barrier to intervening during emergencies.\u003c/p\u003e\n\u003cp\u003eA concern about potentially injuring patients prevents 1,102 (36%) from initiating CPR or resuscitation efforts, while 1,105 (36%) feel that the stigma surrounding unsuccessful attempts discourages involvement in CPR or ACLS training. In addition, 1,138 (37%) believe that the lack of recognition for individuals trained in CPR or ACLS limits their motivation to improve and develop their skills.\u003c/p\u003e\n\u003cp\u003eGeographic isolation which restricts access to emergency services and training was noted as an issue by 1,462 (47%), whereas 598 (20%) participants identified language barriers as a significant obstacle to receiving proper CPR and ACLS training.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe quality of performing Cardiopulmonary Resuscitation (CPR) is directly linked to survival rates, particularly when the time between cardiac arrest and the first defibrillator shock is minimized [1-5]. Immediate bystander CPR remains the most critical factor in improving outcomes for cardiac arrest patients, as it bridges the gap until professional medical help arrives. [14] Our study identifies large gaps in CPR knowledge, attitudes, and practices, similar to other studies, indicating the need for improved training and education globally.\u003c/p\u003e\n\u003cp\u003eFindings from this study revealed that overall CPR knowledge among participants was only 44%, with notable deficiencies in critical areas. For instance, only 20% of respondents correctly identified the recommended chest compression rate for adults, and just 26% recognized the correct compression rate for infants. Knowledge of infant-specific CPR\u0026mdash;such as compression depth (31%) and ventilation ratios (48%) was also low. The lower proficiency in Infant-specific CPR when compared to Adult-specific CPR is similar to findings in earlier studies [7]. This discrepancy is likely due to the predominant focus on Adult-specific CPR during foundational training.\u003c/p\u003e\n\u003cp\u003eOnly 20% of respondents could correctly identify the recommended chest compression rate for adults, and only 45% recognized the signs of adequate compression depth. These results align with previous studies; a 2017 study conducted in Nigeria revealed a significant lack of CPR knowledge among healthcare providers - awareness regarding the use of defibrillators scored the lowest in both knowledge and practice assessments. [1] Deficiencies in CPR knowledge have been consistently reported among doctors and medical students from other developing countries like Ecuador, Egypt, Ethiopia and Nigeria [7-9, 11]. Participants from outside Sudan showed slightly better overall knowledge scores (45%) compared to 44% for all participants; yet deficiencies in this group were prominent in infant-specific CPR (36%) and recognizing adequate ventilation (43%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany of our participants indicated that they rarely practice or update their CPR skills, while a majority admitted never practicing CPR at all. A previously conducted study revealed significant deficits in CPR practice, with limited retraining sessions [10]. Our study also showed that most healthcare providers do not review BLS and CPR guidelines regularly and very few review these guidelines annually or biannually. Records showed that most respondents felt unqualified to teach CPR and other life-support skills such as BLS and Advanced Trauma Life Support (ATLS). A study conducted in Nigerian medical schools found high levels of CPR knowledge and AED identification among students. However, most participants had never performed CPR in real-life scenarios despite undergoing training [8]. Our study includes medical students, who may be expected to have a lower level of knowledge about CPR, as indicated by a study conducted in Saudi Arabia.It could be the fact that our study has medical students, a lower level of knowledge about CPR may be expected as reported in a study in Saudi Arabia. [15] A Lancet study argued that current CPR guidelines are mostly designed for high resource contexts making its effective learning and implementation be difficult in low resource health systems due to\u0026nbsp;the lack of health workers and equipment. [16]\u0026nbsp;A global meta analysis on out of hospital cardiac arrest found higher treatment rates in North America and Europe [17].\u0026nbsp;Regardless, all these knowledge gaps and misconceptions highlight the need for global collaboration to improve in CPR training and education in both high and limited resource contexts to develop versatile and competent health workers [18].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite the knowledge gaps, participants demonstrated generally positive attitudes toward CPR training. A majority (64%) believed that healthcare providers should receive regular CPR training, while 58% advocated for free CPR training for the public. Nearly half (48%) suggested integrating CPR education into school curricula to promote civic responsibility, and 56% recommended making CPR training a mandatory component of workplace safety programs. Previous studies reflected a strong willingness to improve CPR education and accessibility however this knowledge was not consistently matched by adequate skills and practice. [8] This is unlike another study performed in Ethiopia where two-thirds of the participants had poor knowledge about CPR and more than half of the participants had unfavourable attitudes towards CPR showing a stronger relationship between knowledge and attitudes at extended levels [17, 19].\u003c/p\u003e\n\u003cp\u003eThe majority of respondents expressed confidence in their ability to perform CPR in emergency situations. Furthermore, most agreed that CPR training should be included in school curricula. The records indicate that CPR training should be viewed as a civic responsibility and play a critical role in workplace safety. Respondents also believe that employers and drivers should provide ongoing interactive sessions for recertification and maintenance of CPR certification. Many respondents said that making CPR training affordable or free for the public, along with awareness campaigns, would enhance understanding of the importance of CPR.\u003c/p\u003e\n\u003cp\u003eOur study also showed some fears and misconceptions regarding CPR. For example, 36% of participants reported fear of causing injury during CPR, and 35.8% cited the stigma associated with unsuccessful resuscitation attempts as a deterrent. Additionally, fear of legal liability discouraged 36% from intervening in public settings. It is notable that ethical and legal aspects of CPR need to be clarified to health workers including consent and legal liability as per country laws to improve health workers confidence in performing CPR and ensuring quick resuscitation. [20, 21]\u003c/p\u003e\n\u003cp\u003eLack of access to regular BLS training sessions was reported by 63% of participants. Geographic isolation was considered a barrier by 47% of respondents which can be interpreted as further limited access to BLS training. Additionally, 42% pointed to limited availability of CPR materials and resources as a significant barrier, 20% mentioned language barriers to learning CPR, while 33% cited cultural and religious considerations as discouraging factors. Other barriers included fear of legal liability (36%), fear of causing injury (36%), and a perceived lack of recognition or appreciation for trained individuals (37%). In the literature, barriers to effective CPR performance were frequently attributed to insufficient practice, a lack of access to BLS training, and inadequate support from colleagues [9]. Enhancing CPR training modalities to account for these barriers could involve hands-on exercises and peer-learning approaches. Limited access to training and bystander CPR tools, particularly in geographically isolated areas, further exacerbates this issue [11]. Other challenges include language barriers, religious beliefs, and the unaffordable costs of some CPR training programs [7]. A lack of confidence in BLS skills was also identified as a major barrier to performing CPR, with approximately 35% of healthcare providers expressing hesitation due to fear of causing injury [8]. Such fears can lead to a stigma around CPR if attempts are unsuccessful.\u003c/p\u003e\n\u003cp\u003eNearly half of the participants (47%) rarely or never practice their CPR skills. Additionally, 28% rarely updated their knowledge, and only 18% regularly attended workshops or courses to refresh their skills. Studies show that CPR proficiency declines rapidly without reinforcement, often within months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOver 25% of participants had never performed CPR on a real patient, further highlighting the gap between theoretical knowledge and practical application. Frequent retraining of healthcare providers is vital to improving CPR outcomes\u0026mdash;this should occur every two years, at least to refresh less common concepts of CPR [3].A study conducted in Malaysia to assess the CPR resuscitation among COVID-19 patients found low standards of practice in ventilation techniques, use of supraglottic devices, and intubation barriers despite good performance and knowledge in other areas. [22]\u003c/p\u003e\n\u003cp\u003eA study found that short distributed CPR training on a mannequin is effective in improving CPR performance, with a month being the best spacing between CPR training sessions. [23, 24] This aligns with findings that highlight how infrequent training leads to rapid skill degradation, with CPR proficiency declining within months of training if not regularly reinforced. [24] Moreover feedback through CPR feedback technology and CPR coaches can improve CPR quality in resuscitation teams [25].\u003c/p\u003e\n\u003cp\u003eA significant proportion of participants (46%) had never been trained to use an AED, and only 16% reported successfully using one in a real-life situation. A study conducted among the general public found increased knowledge about AEDs improved public perceptions about these devices and their importance in increasing survivability [26]. \u0026nbsp; Another study found strong correlation between knowledge about AEDs and willingness to employ these devices in resuscitation [27].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eLimitations\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the convenience sampling methods adopted for data collection, data may not accurately represent the global population. Furthermore most studies in this field are general and require more in depth analysis of specific attitudes and practices related to CPR.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed that while attitudes toward CPR were generally positive, gaps in knowledge, training and lack of hands-on practice, and updated guidelines hinder effective CPR performance. Medical schools and public health authorities should work in tandem to address barriers to emergency resuscitation. Regular retraining, integration of CPR education into academic and workplace programs, and increasing public awareness about CPR can enhance knowledge, attitudes and practical application of CPR.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthical approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval of the study was obtained from the IRB of Alzaiem Alazhari University. Informed written consent from each participant was guaranteed before partaking in the study and confidentiality of the participants was secured. The study was carried out according to the relevant ethical guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and material\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available and can be accessed through the link: https://osf.io/87su6/?view_only=100ae01aef32498eacc2327606dfe81f. The data are intended for publication as an online data supplement\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made a significant contribution to the study reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003eClinical trial number: Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAliyu I, Michael G, Ibrahim H, Ibrahim Z, Idris U, Zubayr B, et al. 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J Am Heart Assoc 2017;6(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlRadini FA, Sabbagh AY, Alamri FA, Almuzaini Y, Alsofayan YM, Alahmari AA, et al. Application of automated external defibrillators among the public: a cross-sectional study in Saudi Arabia. Int J Gen Med. 2023;16:5089\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDafallah I. Enhancing global understanding of cardiopulmonary resuscitation proficiency. OSF; 2024 [updated 2024-11-26]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/87su6/?view_only=100ae01aef32498eacc2327606dfe81f\u003c/span\u003e\u003cspan address=\"https://osf.io/87su6/?view_only=100ae01aef32498eacc2327606dfe81f\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cardiopulmonary resuscitation, CPR proficiency, medical education, healthcare training, global health, knowledge gaps","lastPublishedDoi":"10.21203/rs.3.rs-5986888/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5986888/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eCardiac arrest remains a critical global health challenge with low survival rates. This study aims to assess the proficiency of cardiopulmonary resuscitation (CPR) among medical students and practitioners across multiple countries, identifying knowledge gaps and barriers to effective practice.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA descriptive, cross-sectional online survey was conducted in April 2024, targeting medical students and healthcare practitioners worldwide. A total of 3,084 participants from 44 countries completed the survey, which evaluated CPR knowledge, attitudes, practices, and perceived barriers. Statistical analysis was performed using SPSS v28.0.0.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eOverall CPR knowledge among participants was only 44%, with significant deficiencies in critical areas such as chest compression rates for adults (20%) and infants (26%). Notably, 63% cited lack of access to training as a major barrier, while 64% emphasized the necessity for regular CPR training for healthcare providers. Positive attitudes towards integrating CPR training into educational curricula were observed, with 58% supporting free community training initiatives.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe study highlights significant gaps in CPR knowledge and practice among medical students and practitioners, underscoring the need for enhanced training programs. Implementing regular CPR education and addressing identified barriers can improve preparedness and outcomes in cardiac arrest situations globally.\u003c/p\u003e","manuscriptTitle":"Enhancing Global Understanding of Cardiopulmonary Resuscitation (CPR) Proficiency Among Medical Students and Practitioners","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-29 12:01:01","doi":"10.21203/rs.3.rs-5986888/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be0e14a4-be29-41df-b97a-57ec574a92e0","owner":[],"postedDate":"September 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T12:01:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-29 12:01:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5986888","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5986888","identity":"rs-5986888","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}