Hospital-school collaborative standardized cardiopulmonary resuscitation training improves first aid literacy in adolescents: A large-sample study in Guangzhou

Hospital-school collaborative standardized cardiopulmonary resuscitation training improves first aid literacy in adolescents: A large-sample study in Guangzhou | 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 Hospital-school collaborative standardized cardiopulmonary resuscitation training improves first aid literacy in adolescents: A large-sample study in Guangzhou Pengfei Wang, Junpeng Tang, Ting Liang, Shunhua Ye, Chaotao Zeng, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9260068/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Objective To evaluate the effect of hospital-school collaborative standardized cardiopulmonary resuscitation (CPR) training on CPR knowledge, first aid attitude and willingness to perform rescue in 15-17-year-old middle and vocational high school students in Guangzhou, and analyze subgroup differences by school type and gender, so as to provide evidence for constructing a normalized adolescent first aid training model. Methods A multi-stage cluster sampling method was used to select 11589 students from 9 schools (4 high schools, 5 vocational high schools) in 6 administrative districts of Guangzhou. Standardized CPR training based on the 2020 AHA Guidelines (1 h theory + 2 h practical operation + one-on-one guidance) was implemented by professional medical teams. Unified questionnaires were used to assess CPR knowledge (full score 10), first aid attitude and rescue willingness before and after training. R 4.3.1 was used for statistical analysis (paired t -test for quantitative data, χ² test for categorical data). Results A total of 6549 valid post-training samples were included, with vocational high school students accounting for 81.8% and girls 63.9%. The total CPR knowledge score increased significantly from 5.73 ± 2.03 to 8.87 ± 1.61 ( P < 0.001). The correct rate of 10 core knowledge points increased by 14.8% − 42.2%, with the increase of “AED usage timing”, “chest compression depth” and “unresponsive choking management” exceeding 40%. The willingness to perform rescue rose from 88.7% to 94.3% ( P < 0.001), while the proportion of training fear increased slightly from 13.7% to 14.6% ( P = 0.100). Subgroup analysis showed that vocational high school students had a higher pre-training knowledge score than high school students (5.85 ± 2.03 vs 5.2 ± 1.94, P < 0.001), and girls had a higher score than boys (5.89 ± 2.00 vs 5.46 ± 2.06, P = 0.03). After training, the knowledge gap between the two school types narrowed from 0.65 to 0.12 points, and there was no significant gender difference in knowledge scores ( P = 0.36). Students with previous CPR training history had significantly higher pre-training knowledge scores than those without (5.92 ± 1.98 vs 5.58 ± 2.05, P < 0.001). Conclusion Hospital-school collaborative standardized CPR training by professional medical teams can significantly improve CPR knowledge and rescue willingness of adolescents, and effectively narrow the ability gap between different school types and genders. It provides a practical intervention path for improving adolescent first aid literacy, improving the community emergency "chain of survival" and enhancing the prognosis of out-of-hospital cardiac arrest (OHCA). Adolescents Cardiopulmonary resuscitation training First aid literacy Hospital-school collaboration Out-of-hospital cardiac arrest Figures Figure 1 Figure 2 Figure 3 Highlights 1. Hospital-school collaborative standardized CPR training significantly improved adolescents’ CPR knowledge and rescue willingness. 2. The training effectively narrowed the first aid ability gap between high school and vocational high school students, and between genders. 3. Key knowledge points with low baseline cognition (AED usage, choking management) achieved the most significant improvement. 4. Previous CPR training history had a cumulative effect on knowledge mastery and skill learning efficiency. 5. The 3-hour standardized training model (1 h theory + 2 h practical) is suitable for large-scale promotion among adolescents. 1. Introduction Out-of-hospital cardiac arrest (OHCA) is a major global public health challenge with extremely low survival rates worldwide. In China, the annual incidence of OHCA is about 95.7 per 100,000 population, with a 30 - day survival rate of only 1.2%, far lower than that in the United States (10.8%) and European countries (3.1% − 20.4%) [ 1 ]. The survival of OHCA patients highly depends on the rapid activation of the "chain of survival", and bystander cardiopulmonary resuscitation (CPR) is the core link: every 1-minute delay in CPR reduces the patient’s survival rate by 7% − 10%, and CPR initiated within 4 minutes can increase the survival rate by 3–4 times [ 2 , 3 ]. However, the rate of bystander CPR in China is only 20.3%, and the public utilization rate of automated external defibrillator (AED) is less than 0.1%, which is far from meeting the demand for improving OHCA prognosis [ 4 ]. Adolescents are a potential rescuer group with wide distribution and rapid response in the community, and the systematic cultivation of their CPR ability is of strategic significance for improving the overall first aid level of the population. The European Resuscitation Council (ERC), American Heart Association (AHA) and World Health Organization (WHO) all clearly recommend that CPR training should be incorporated into the regular education system from the age of 12, combined with standardized theoretical and practical training [ 5 , 6 ]. Longitudinal cohort studies have confirmed that the willingness and behavior of rescue after CPR training in adolescence can persist into adulthood, which has a long-term promoting effect on the improvement of community OHCA survival rate [ 7 ]. Existing studies have verified the feasibility of adolescent CPR training: a large-scale training covering more than 330,000 middle school students in the United States showed that the knowledge score increased from 50% to 84% after training [ 8 ]; in Slovenia, the average theoretical knowledge score of 12-15-year-old students increased by 1.48–2.65 points after training [ 9 ]. However, there are obvious gaps in current research: first, the lack of large-sample, multi-center standardized training effect analysis for 15-17-year-old middle and vocational high school students, and most studies focus on college students or single school groups with small sample sizes; second, non-professional teachers often lead adolescent CPR training, resulting in inadequate operation guidance [ 10 ]; third, the problem of skill attenuation is prominent, and the standardized training model and retraining mechanism for middle school students are not yet formed [ 10 ]. Vocational high school students may have different training foundations from high school students due to the focus on practical skills in their courses, but relevant subgroup analysis is rare. Professional medical staff-led training combined with real-time feedback can significantly improve the quality of CPR operation [ 11 ], which is the key to solving the above problems. This study took 15-17-year-old middle and vocational high school students in Guangzhou as the research object, implemented standardized CPR training through the hospital-school collaboration model, and comprehensively evaluated the changes in students’ CPR knowledge, first aid attitude and rescue willingness, in order to provide data support for the construction of a normalized adolescent first aid training system. 2. Methods 2.1 Study subjects 2.1.1Sampling method and sample size A multi-stage cluster sampling method was adopted from 2023 to 2025 (Fig. 1 ). First, stratified by "high school/vocational high school", 9 schools (4 high schools, 5 vocational high schools) in 6 administrative districts (Tianhe, Yuexiu, Haizhu, Panyu, Baiyun, Nansha) of Guangzhou were randomly selected, and then students were included by class as a cluster (11,589 students in total). Finally, 9525 valid pre-training samples and 6549 valid post-training samples were obtained, with a sample loss rate of 30.6% (main reasons: absent courses, incomplete questionnaire filling, contradictory repeated answers). 2.1.2 Inclusion and exclusion criteria Inclusion criteria 1. 15-17-year-old students in public/private middle schools and vocational high schools in Guangzhou; 2. Voluntarily participate in the study with informed consent signed by guardians; 3. Able to independently complete the pre and post-training questionnaires without cognitive or reading and writing disorders (Fig. 2 ). Exclusion criteria 1. Absent from ≥ 50% of theoretical or practical courses during training; 2. Missing ≥ 3 key items in pre or post-training questionnaires; 3. Contradictory answers to repeated questions (questions on CPR compression position). 2.2 Training team and teacher preparation The core teaching team consisted of 30 medical staff from the Emergency Department of Sun Yat-sen Memorial Hospital of Sun Yat-sen University, including 2 chief physicians, 2 associate chief physicians, 4 attending physicians, 4 physicians, 1 chief nurse, 8 nurse supervisors and 11 nurses, all with more than 5 years of emergency clinical experience or AHA Basic Life Support (BLS) instructor qualification. Two weeks before the training, the teaching team received 16 h of standardized teacher training, including the core points of the 2020 AHA CPR Guidelines, adolescent teaching skills, questionnaire assessment specifications, and a combined theoretical and practical assessment (pass score ≥ 90 points). 2.3 Training content and process A combined "theory + practical operation" model was adopted with a total duration of 3 h, and the specific process is shown in Table 1 . Laerdal Resusci Anne adult CPR manikins were used for skill demonstration and practical operation, with 1 teacher guiding 10 students in each group to ensure one-on-one error correction and feedback. Table 1 Training content and process of standardized CPR Session Duration (min) Core content Theoretical teaching 60 Identification of cardiac arrest, core steps of CPR (C-A-B), key parameters of chest compression, artificial respiration and AED usage, first aid ethics and laws Skill demonstration 30 Standard operation demonstration with adult CPR manikins, emphasizing palm root positioning, arm straightening and chest recoil Student practical operation 60 10 students per group (1 teacher guidance), each student completes 3 sets of complete CPR (30 compressions + 2 breaths) with one-on-one error correction Q&A and summary 30 Answer practical operation questions, sort out core knowledge points and common operation misunderstandings Note: CPR = Cardiopulmonary Resuscitation; AED = Automated External Defibrillator. 2.4 Evaluation tools and indicators 2.4.1 Questionnaire design Referring to the AHA adolescent CPR assessment tool and domestic relevant studies, a unified paper-based pre and post-training questionnaire was designed with the same structure (16 questions in total), including three dimensions: general information (school type, gender, age), attitude and previous training (5 questions: training necessity cognition, training willingness, training fear, rescue willingness, previous CPR training history), and CPR knowledge (11 questions, full score 10). The knowledge questions covered 10 core points such as chest compression speed, compression position, AED usage timing, and unresponsive choking management (repeated questions on compression position were both answered correctly to get 1 point, otherwise the questionnaire was excluded). The questionnaire used in this study was developed by the authors based on a review of the relevant literature and expert consultation. The full English version of the questionnaire is provided in Supplementary Material 1–3. 2.4.2 Evaluation time and quality control Pre-training test: Completed independently by students before the start of theoretical courses, with on-site verification of completeness; Post-training test: Completed independently by students after the end of practical courses without mutual communication. Quality control measures: Uniform distribution and recovery of questionnaires by the research team; double entry of data with EpiData 3.1 and logical verification + manual proofreading; unified teaching language and operation standards by the teaching team to avoid teaching deviation. 2.5 Statistical analysis R 4.3.1 software was used for statistical analysis. Quantitative data (age, total knowledge score) were expressed as mean ± standard deviation ( \(\:\text{x}\text{±}\text{s}\) ), with paired t -test for pre and post-training comparison and independent sample t -test for subgroup comparison. Categorical data (gender composition, attitude/willingness proportion, single question correct rate) were expressed as frequency (percentage), with χ² test for pre and post-training and subgroup comparison. The test level α = 0.05, P < 0.05 was considered statistically significant. 3. Results 3.1 Baseline characteristics of the study subjects A total of 9525 valid pre-training samples were included, with an average age of 15.2 ± 0.42 years (range 15–17 years). Among them, 6088 girls (63.9%), 3437 boys (36.1%); 7787 vocational high school students (81.8%), 1738 high school students (18.2%); 4473 students with previous CPR training history (47.0%), 5052 without (53.0%). The proportion of students who thought training was "necessary" was 99.4%, "willing to participate" was 99.1%, "with training fear" was 13.7%, and "willing to perform rescue" was 88.7%. The total pre-training knowledge score was 5.73 ± 2.03 points (Table 2 ). Table 2 Baseline characteristics of the study subjects (pre-training, n = 9525) Characteristic Category n %/ \(\:\text{x}\text{±}\text{s}\) Gender Female 6088 63.9 Male 3437 36.1 School type High school 1738 18.2 Vocational high school 7787 81.8 Age (years) - - 15.2 ± 0.42 Previous CPR training history Yes 4473 47.0 No 5052 53.0 Cognition of training necessity Necessary 9472 99.4 Unnecessary/Unknown 53 0.6 Training willingness Willing 9441 99.1 Unwilling 84 0.9 Training fear Yes 1306 13.7 No 8219 86.3 Willingness to perform rescue Yes 8450 88.7 No 1075 11.3 Total knowledge score (points) - - 5.73 ± 2.03 Note: CPR = Cardiopulmonary Resuscitation. Subgroup baseline comparison showed that the pre-training knowledge score of vocational high school students was significantly higher than that of high school students (5.85 ± 2.03 vs 5.2 ± 1.94, P < 0.001), and that of girls was significantly higher than that of boys (5.89 ± 2.00 vs 5.46 ± 2.06, P = 0.03) (Table 3 ). Table 3 Pre-training CPR knowledge scores of different subgroups ( x ± s , points) Subgroup n Knowledge score P value Gender Female (6088) 5.89 ± 2.00 0.03 Male (3437) 5.46 ± 2.06 School type Vocational high school (7787) 5.85 ± 2.03 < 0.001 High school (1738) 5.2 ± 1.94 3.2 Comparison of CPR knowledge mastery before and after training The total post-training CPR knowledge score was 8.87 ± 1.61 points, which was significantly higher than the pre-training score (Fig. 3 A). The correct rate of all 10 core knowledge points increased significantly after training, with an increase range of 14.8% − 42.2% (Fig. 3 B-L). The correct rate of "unresponsive choking management method" increased the most (35.5% → 77.7%), and the increase of "AED usage timing", "chest compression depth" and "compression position" exceeded 40% (Table 4 ). Table 4 Comparison of the correct rate of core CPR knowledge points before and after training Question No. Core knowledge point Pre-training correct rate (%) Post-training correct rate (%) Increase range (%) χ² value P value 6 Chest compression speed 70.1 95.2 25.1 2846.3 < 0.001 7 Consciousness judgment method 60.0 95.4 35.4 2419.7 < 0.001 8&13 Compression position (inferior sternum) 37.7 78.3 40.6 2287.5 < 0.001 9 Heartbeat judgment position (carotid artery) 73.9 93.4 19.5 1963.2 < 0.001 10 Arm posture for chest compression 63.3 87.2 23.9 2798.6 < 0.001 11 CPR compression-ventilation ratio 83.1 97.9 14.8 2811.4 < 0.001 12 Chest compression depth (adult) 52.0 92.0 40.0 2568.9 < 0.001 14 AED usage timing 37.3 79.2 41.9 2089.4 < 0.001 15 Unresponsive choking management method 35.5 77.7 42.2 1976.5 < 0.001 16 Golden time of CPR 60.4 87.4 27.0 2987.1 < 0.001 Note: CPR = Cardiopulmonary Resuscitation; AED = Automated External Defibrillator. 3.3 Subgroup analysis of knowledge scores After training, the knowledge score gap between high school and vocational high school students narrowed from 0.65 point to 0.12 point, and the gender difference in knowledge scores was no longer statistically significant ( P = 0.36). Students with previous CPR training history had a significantly higher pre-training knowledge score than those without (5.92 ± 1.98 vs 5.58 ± 2.05, P < 0.001), and the post-training improvement amplitude was more significant. 3.4 Comparison of first aid attitude and rescue willingness before and after training After training, the students’ first aid attitude and rescue willingness showed a significant positive change: the proportion of "willing to help when seeing patients on the road" increased from 88.7% to 94.3% (χ² = 213.5, P < 0.001); the proportion of "with training fear" increased slightly from 13.7% to 14.6% ( P = 0.100, no statistical significance); the proportion of "thinking training is necessary" and "willing to participate in training" both remained above 99.1%, with no significant pre and post-training differences ( P > 0.05) (Table 5 ). Table 5 Comparison of first aid attitude and rescue willingness before and after training Indicator Pre-training ( n = 9525) n (%) Post-training ( n = 6549) n (%) χ² value P value Cognition of training necessity Necessary: 9472 (99.4) Necessary: 6526 (99.6) 2.4 0.119 Training willingness Willing: 9441 (99.1) Willing: 6489 (99.1) 0.02 0.888 Training fear Yes: 1306 (13.7) Yes: 959 (14.6) 2.6 0.100 Willingness to perform rescue Yes: 8450 (88.7) Yes: 6176 (94.3) 213.5 < 0.001 3.5 Subgroup analysis of attitude and rescue willingness 3.5.1 School type subgroup After training, the proportion of "training fear" in high school students (10.1%) was significantly lower than that in vocational high school students (15.7%) (χ² = 41.2, P < 0.001); the proportion of "willing to perform rescue" in high school students (95.2%) was slightly higher than that in vocational high school students (94.1%), with no statistical significance (χ² = 2.1, P = 0.153); the proportion of vocational high school students with previous CPR training history (60.9%) was significantly lower than that of high school students (70.3%) (χ² = 47.8, P < 0.001). 3.5.2 Gender subgroup There was no significant difference in the proportion of "training fear" between boys and girls before training ( P = 0.699); after training, the proportion of "training fear" in boys was slightly higher than that in girls, with no statistical significance (χ² = 2.6, P = 0.105). The proportion of "willing to perform rescue" in girls (65.4%) was slightly higher than that in boys (34.6%) after training, with no statistical significance (χ² = 3.8, P = 0.052). 4. Discussion This study confirmed that hospital-school collaborative standardized CPR training by professional medical teams can significantly improve the CPR knowledge mastery and rescue willingness of 15-17-year-old adolescents in Guangzhou, and effectively narrow the first aid ability gap between different school types and genders, which has important public health significance for optimizing the community emergency "chain of survival" and improving the OHCA prognosis. 4.1 The "three-dimensional empowerment" effect of standardized training The training realizes the collaborative improvement of students’ knowledge, skills and psychology: in terms of knowledge, the core points with low baseline cognition (AED usage, choking management, compression position) achieved the most significant improvement, which is due to the combination of targeted theoretical explanation and one-on-one practical operation guidance in the training, making up for the deficiency of adolescent’s fragmented first aid knowledge acquisition in daily life; in terms of psychology, the rescue willingness increased by 5.6 percentage points while the training fear did not increase significantly, indicating that the standardized practical operation reduced students’ fear of actual rescue and enhanced their self-efficacy in first aid. This is consistent with the conclusion of Riggs et al [ 11 ] that professional medical staff-led training can improve the psychological acceptance of CPR for adolescents. 4.2 The cumulative effect of previous training history and the necessity of retraining Students with previous CPR training history had significantly higher pre-training knowledge scores and more significant post-training improvement, which confirmed the cumulative effect of CPR training: the initial training lays the foundation of knowledge and skills, and the standardized re-training realizes the consolidation and improvement of abilities. Combined with the existing research that adolescent CPR skills begin to attenuate 3 months after training without retraining [ 10 ], it is suggested that a regular retraining mechanism (such as annual re-training) should be established in the follow-up to maintain the long-term effectiveness of training. 4.3 The balanced improvement effect of subgroup differences and the enlightenment of inclusive training The pre-training knowledge gap between different school types and genders is closely related to their educational background and learning characteristics: vocational high school students have more opportunities to contact practical skills related to first aid due to the practice-oriented curriculum, so their pre-training scores are higher; girls have advantages in theoretical knowledge learning due to their attention to details [ 7 ]. After training, the gap is significantly narrowed, which is the core value of the standardized and inclusive training model in this study: the unified teaching content and one-on-one guidance make up for the deficiency of high school students in practical operation and boys in theoretical knowledge, realizing the balanced improvement of different groups. For school type differences, the follow-up training can adopt the mode of "universal content + personalized focus": strengthen the practical scene simulation for high school students, and increase the first aid scene expansion combined with professional courses for vocational high school students (such as ward first aid simulation for nursing major). For gender differences, give play to the complementary advantages of genders: strengthen the guidance of compression position accuracy for boys, and increase the chest compression strength training for girls with the help of elastic bands, so as to realize the maximization of training effect. 4.4 The promotion value of hospital-school collaboration model The hospital-school collaboration model solves the core problems of adolescent first aid training such as non-professional teachers and inadequate operation guidance: professional medical teams ensure the standardization of training content and operation, and schools provide the carrier and coverage of training, forming a win-win pattern of "medical resource sinking and school quality education improvement". The 3-hour training model (1 h theory + 2 h practical) in this study is highly compatible with the middle school curriculum arrangement, and is suitable for large-scale promotion in adolescents. At the same time, the 94.3% post-training rescue willingness means that students will become the "seed group" of community first aid, and realize the radiation and dissemination of first aid knowledge from "students to families and communities", which is of great significance for improving the overall first aid level of the population. 4.5 Study limitations This study has certain limitations: first, the sample is limited to urban schools in Guangzhou, and the popularization of the training model in rural and central and western regions needs to be verified by multi-center studies; second, the study lacks a control group, and the potential impact of social first aid publicity cannot be excluded; third, only the short-term effect of training is evaluated, and the long-term retention of CPR knowledge and skills needs to be further tracked by follow-up surveys; fourth, the evaluation indicators are mainly subjective questionnaires, and the combination of objective operation indicators (such as compression depth and speed compliance rate) can make the evaluation more comprehensive. 5. Conclusion Hospital-school collaborative standardized CPR training implemented by professional medical teams can significantly improve the CPR knowledge mastery and rescue willingness of 15-17-year-old middle and vocational high school students, effectively narrow the first aid ability gap between different school types and genders, and verify the feasibility and popularization of this model. This model provides a practical intervention path for improving adolescent first aid literacy, perfecting the community emergency "chain of survival" and improving the prognosis of OHCA. In the future, it is necessary to build a normalized adolescent first aid training system relying on policy support, improve the long-term effectiveness of training through the establishment of a regular retraining mechanism, and expand the coverage of training to rural and remote areas, so as to provide a solid support for improving the national first aid ability and the level of public health emergency response. Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Sun Yat-sen Memorial Hospital, Sun Yat-sen University(Approval No. SYSKY-2024-759-01). Written informed consent was obtained from all participants prior to their inclusion in the study. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Conflict of interest The authors declare that they have no competing interests. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contributions Conceptualization: Wang Pengfei; Methodology: Wang Pengfei, Song Fengqing; Formal analysis: Tang Junpeng; Investigation: Liang Ting;Ye Shunhua; Li Li;Wang Peng; Data curation: Liang Ting, Feng Xiaowei; Zeng Chaotao; Visualization & Software : Tang Junpeng; Writing – Original Draft: Wang Pengfei; Writing – Review & Editing: Yu Tao, Song Fengqing; Supervision: Liu Wandi. Acknowledgements The authors thank all the medical staff of the Emergency Department of Sun Yat-sen Memorial Hospital of Sun Yat-sen University for their hard work in the CPR training and data collection, and all the participating schools and students in Guangzhou for their active cooperation in this study. Declaration of generative AI and AI-assisted technologies in the manuscript preparation process During the preparation of this work, the authors used AI writing tools only for language polishing and structural optimization of the manuscript. After using the tool, the authors reviewed and edited the content in detail, and take full responsibility for the content of the published article. References Shao H, Li CS. Epinephrine in Out-of-hospital Cardiac Arrest: Helpful or Harmful? Chin Med J (Engl). 2017;130:2112–6. Holmberg M, Holmberg S, Herlitz J. The problem of out-of-hospital cardiac-arrest prevalence of sudden death in Europe today. Am J Cardiol. 1999;83:D88–90. Holmberg M, Holmberg S, Herlitz J. Factors modifying the effect of bystander cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in Sweden. Eur Heart J. 2001;22:511–9. Chen M, Wang Y, Li X, et al. Public Knowledge and Attitudes towards Bystander Cardiopulmonary Resuscitation in China. 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Disseminating Cardiopulmonary Resuscitation Training by Distributing 35 000 Personal Manikins Among School Children. Circulation. 2007;116:1380–5. Ocampo Cervantes AB, López López CA, Cerezo Espinosa C, et al. Virtual reality versus theoretical training in CPR among adolescents: a randomized trial with a one-year longitudinal follow-up. Resusc Plus. 2026;27:101178. Riggs M, Franklin R, Saylany L. Associations between cardiopulmonary resuscitation (CPR) knowledge, self-efficacy, training history and willingness to perform CPR and CPR psychomotor skills: A systematic review. Resuscitation. 2019;138:259–72. Additional Declarations No competing interests reported. Supplementary Files AppendixTableswithAnnotations.docx SupplementaryMaterial2PosttrainingQuestionnaire.docx SupplementaryMaterial3InformedConsentForm.docx SupplementaryMaterial1PretrainingQuestionnaire.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 May, 2026 Reviews received at journal 06 May, 2026 Reviewers agreed at journal 04 May, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviewers invited by journal 24 Apr, 2026 Editor assigned by journal 23 Apr, 2026 Editor invited by journal 04 Apr, 2026 Submission checks completed at journal 03 Apr, 2026 First submitted to journal 03 Apr, 2026 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. 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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-9260068","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634336367,"identity":"f1438c36-7962-45ac-907f-d451cb705def","order_by":0,"name":"Pengfei Wang","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pengfei","middleName":"","lastName":"Wang","suffix":""},{"id":634336368,"identity":"17492895-ab07-46f4-b008-932ba3869ca3","order_by":1,"name":"Junpeng Tang","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Junpeng","middleName":"","lastName":"Tang","suffix":""},{"id":634336369,"identity":"780b9adf-d91a-4d94-baf8-7b3ac16ab661","order_by":2,"name":"Ting Liang","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ting","middleName":"","lastName":"Liang","suffix":""},{"id":634336370,"identity":"7f92d5d7-51a4-4342-a0d2-8a096ea0bc2d","order_by":3,"name":"Shunhua Ye","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shunhua","middleName":"","lastName":"Ye","suffix":""},{"id":634336371,"identity":"8356bd84-7f96-4843-8464-d62279b7cb6c","order_by":4,"name":"Chaotao Zeng","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chaotao","middleName":"","lastName":"Zeng","suffix":""},{"id":634336372,"identity":"77a421f7-9fac-4af6-888a-e0cb33715423","order_by":5,"name":"Xiaowei Feng","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaowei","middleName":"","lastName":"Feng","suffix":""},{"id":634336373,"identity":"cd5b7e75-634d-4b56-9af4-1d7e99cd7f05","order_by":6,"name":"Li Li","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Li","suffix":""},{"id":634336374,"identity":"60e0f4f5-b2cc-4bc3-9127-649b1fc917f9","order_by":7,"name":"Peng Wang","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peng","middleName":"","lastName":"Wang","suffix":""},{"id":634336375,"identity":"2c4dfa29-fd7a-4bf1-b45a-0c227faf96cf","order_by":8,"name":"Wandi Liu","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wandi","middleName":"","lastName":"Liu","suffix":""},{"id":634336377,"identity":"ea0d2fc8-7b29-4b19-84c8-25d3513acbb5","order_by":9,"name":"Fengqing Song","email":"","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fengqing","middleName":"","lastName":"Song","suffix":""},{"id":634336379,"identity":"294c1ca0-82c3-4981-b471-3f2cbbb22406","order_by":10,"name":"Tao Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYHACxgcMDBIycF4DYR3MzAZALTwkaWGTAJIkaDG4kX+s6kaNBQ8D/xnjzzwMNrIbDjA/e4BfSzLb7ZxjQIdJ5JhJ8zCkGW84wGZuQFgLG0gLjxkzD8PhxA0HeMBOxaulOOefBMxh/4nTwpzbBgqxHAOgww4Q1iJ55rGxdG6fBFBZWpnkHINk45mH2czwauE7nvjwc863Ojl+/sObP7ypsJPtO978DK8WhQNQBhsDBzCcQEHFjE89EMg3wJnsDwioHQWjYBSMgpEKALQdPuQtFPk6AAAAAElFTkSuQmCC","orcid":"","institution":"Sun Yat-sen Memorial Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tao","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2026-03-29 16:25:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9260068/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9260068/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108546248,"identity":"f84957ba-a6f3-41da-a32e-405e6d6750e7","added_by":"auto","created_at":"2026-05-05 20:39:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1804524,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWorkflow of the adolescent CPR training program.\u003cbr\u003e\n \u003c/strong\u003eThe schematic illustrates teacher preparation, classroom training, and student evaluation. Training was delivered by qualified instructors using a theory–practice model with CPR manikins. Learning outcomes were assessed using pre- and post-training questionnaires, with standardized data management and quality control. CPR, cardiopulmonary resuscitation.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-9260068/v1/a85f21db5993b377d4c63b17.png"},{"id":108804840,"identity":"b6ef0fb0-b419-407a-a13c-2ddcfdd391aa","added_by":"auto","created_at":"2026-05-08 15:23:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":522322,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipant flow diagram of the study.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 11,589 participants receiving CPR training were initially assessed. After excluding 4,174 uncollected questionnaires and 2,930 questionnaires with missing demographic information or invalid responses, 16,074 questionnaires were included in the final analytical sample. Among these, 9,525 participants completed the pre-test and 6,549 completed the post-test.CPR, cardiopulmonary resuscitation.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-9260068/v1/929570026c3e02f946bf646a.png"},{"id":108546222,"identity":"bd4bd238-61a5-4072-ade9-09117c2db4f9","added_by":"auto","created_at":"2026-05-05 20:39:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5127091,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic diagram of the adolescent CPR training program and evaluation process.\u003cbr\u003e\n \u003c/strong\u003eThe diagram illustrates teacher preparation, classroom-based CPR training, and pre- and post-training evaluation with standardized data quality control. Abbreviation: CPR, cardiopulmonary resuscitation. *P \u0026lt; 0.05, **P \u0026lt; 0.01, ***P \u0026lt; 0.001.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-9260068/v1/168fcbe1ac4d848a313956e4.png"},{"id":108814700,"identity":"6cfb4216-8ab0-4a8f-b844-01bd7186e79c","added_by":"auto","created_at":"2026-05-08 16:19:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6586771,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9260068/v1/2e197743-40b9-420a-9427-a2ec7136c002.pdf"},{"id":108546226,"identity":"dee1a93d-9fb7-4375-a4ce-8d93b4dd626b","added_by":"auto","created_at":"2026-05-05 20:39:30","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":18122,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixTableswithAnnotations.docx","url":"https://assets-eu.researchsquare.com/files/rs-9260068/v1/6cc03249d8f7467563858c57.docx"},{"id":108546227,"identity":"f4cdf2cb-5b79-422d-ac7a-b2aef02a30e9","added_by":"auto","created_at":"2026-05-05 20:39:30","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":15067,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial2PosttrainingQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-9260068/v1/e08dc6911d6c30161104c1c4.docx"},{"id":108546230,"identity":"93045be1-8d4b-4116-9e62-718da961f470","added_by":"auto","created_at":"2026-05-05 20:39:31","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":17751,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial3InformedConsentForm.docx","url":"https://assets-eu.researchsquare.com/files/rs-9260068/v1/b8b4e0e254b4565aaf7492f9.docx"},{"id":108546225,"identity":"524dc199-34d2-4a73-8ec5-b604ceae0248","added_by":"auto","created_at":"2026-05-05 20:39:29","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":15008,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial1PretrainingQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-9260068/v1/8fca611dd39e2269ac8d025c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hospital-school collaborative standardized cardiopulmonary resuscitation training improves first aid literacy in adolescents: A large-sample study in Guangzhou","fulltext":[{"header":"Highlights","content":"\u003cp\u003e1. Hospital-school collaborative standardized CPR training significantly improved adolescents\u0026rsquo; CPR knowledge and rescue willingness.\u003c/p\u003e\u003cp\u003e2. The training effectively narrowed the first aid ability gap between high school and vocational high school students, and between genders.\u003c/p\u003e\u003cp\u003e3. Key knowledge points with low baseline cognition (AED usage, choking management) achieved the most significant improvement.\u003c/p\u003e\u003cp\u003e4. Previous CPR training history had a cumulative effect on knowledge mastery and skill learning efficiency.\u003c/p\u003e\u003cp\u003e5. The 3-hour standardized training model (1 h theory\u0026thinsp;+\u0026thinsp;2 h practical) is suitable for large-scale promotion among adolescents.\u003c/p\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eOut-of-hospital cardiac arrest (OHCA) is a major global public health challenge with extremely low survival rates worldwide. In China, the annual incidence of OHCA is about 95.7 per 100,000 population, with a 30 - day survival rate of only 1.2%, far lower than that in the United States (10.8%) and European countries (3.1% \u0026minus;\u0026thinsp;20.4%) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The survival of OHCA patients highly depends on the rapid activation of the \"chain of survival\", and bystander cardiopulmonary resuscitation (CPR) is the core link: every 1-minute delay in CPR reduces the patient\u0026rsquo;s survival rate by 7% \u0026minus;\u0026thinsp;10%, and CPR initiated within 4 minutes can increase the survival rate by 3\u0026ndash;4 times [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the rate of bystander CPR in China is only 20.3%, and the public utilization rate of automated external defibrillator (AED) is less than 0.1%, which is far from meeting the demand for improving OHCA prognosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdolescents are a potential rescuer group with wide distribution and rapid response in the community, and the systematic cultivation of their CPR ability is of strategic significance for improving the overall first aid level of the population. The European Resuscitation Council (ERC), American Heart Association (AHA) and World Health Organization (WHO) all clearly recommend that CPR training should be incorporated into the regular education system from the age of 12, combined with standardized theoretical and practical training [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Longitudinal cohort studies have confirmed that the willingness and behavior of rescue after CPR training in adolescence can persist into adulthood, which has a long-term promoting effect on the improvement of community OHCA survival rate [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExisting studies have verified the feasibility of adolescent CPR training: a large-scale training covering more than 330,000 middle school students in the United States showed that the knowledge score increased from 50% to 84% after training [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; in Slovenia, the average theoretical knowledge score of 12-15-year-old students increased by 1.48\u0026ndash;2.65 points after training [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, there are obvious gaps in current research: first, the lack of large-sample, multi-center standardized training effect analysis for 15-17-year-old middle and vocational high school students, and most studies focus on college students or single school groups with small sample sizes; second, non-professional teachers often lead adolescent CPR training, resulting in inadequate operation guidance [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; third, the problem of skill attenuation is prominent, and the standardized training model and retraining mechanism for middle school students are not yet formed [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVocational high school students may have different training foundations from high school students due to the focus on practical skills in their courses, but relevant subgroup analysis is rare. Professional medical staff-led training combined with real-time feedback can significantly improve the quality of CPR operation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which is the key to solving the above problems. This study took 15-17-year-old middle and vocational high school students in Guangzhou as the research object, implemented standardized CPR training through the hospital-school collaboration model, and comprehensively evaluated the changes in students\u0026rsquo; CPR knowledge, first aid attitude and rescue willingness, in order to provide data support for the construction of a normalized adolescent first aid training system.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study subjects\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003e2.1.1Sampling method and sample size\u003c/h2\u003e \u003cp\u003eA multi-stage cluster sampling method was adopted from 2023 to 2025 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). First, stratified by \"high school/vocational high school\", 9 schools (4 high schools, 5 vocational high schools) in 6 administrative districts (Tianhe, Yuexiu, Haizhu, Panyu, Baiyun, Nansha) of Guangzhou were randomly selected, and then students were included by class as a cluster (11,589 students in total). Finally, 9525 valid pre-training samples and 6549 valid post-training samples were obtained, with a sample loss rate of 30.6% (main reasons: absent courses, incomplete questionnaire filling, contradictory repeated answers).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.1.2 Inclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eInclusion criteria\u003c/strong\u003e \u003cp\u003e1. 15-17-year-old students in public/private middle schools and vocational high schools in Guangzhou; 2. Voluntarily participate in the study with informed consent signed by guardians; 3. Able to independently complete the pre and post-training questionnaires without cognitive or reading and writing disorders (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExclusion criteria\u003c/strong\u003e \u003cp\u003e1. Absent from \u0026ge;\u0026thinsp;50% of theoretical or practical courses during training; 2. Missing\u0026thinsp;\u0026ge;\u0026thinsp;3 key items in pre or post-training questionnaires; 3. Contradictory answers to repeated questions (questions on CPR compression position).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Training team and teacher preparation\u003c/h2\u003e \u003cp\u003eThe core teaching team consisted of 30 medical staff from the Emergency Department of Sun Yat-sen Memorial Hospital of Sun Yat-sen University, including 2 chief physicians, 2 associate chief physicians, 4 attending physicians, 4 physicians, 1 chief nurse, 8 nurse supervisors and 11 nurses, all with more than 5 years of emergency clinical experience or AHA Basic Life Support (BLS) instructor qualification.\u003c/p\u003e \u003cp\u003e Two weeks before the training, the teaching team received 16 h of standardized teacher training, including the core points of the 2020 AHA CPR Guidelines, adolescent teaching skills, questionnaire assessment specifications, and a combined theoretical and practical assessment (pass score\u0026thinsp;\u0026ge;\u0026thinsp;90 points).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Training content and process\u003c/h2\u003e \u003cp\u003eA combined \"theory\u0026thinsp;+\u0026thinsp;practical operation\" model was adopted with a total duration of 3 h, and the specific process is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Laerdal Resusci Anne adult CPR manikins were used for skill demonstration and practical operation, with 1 teacher guiding 10 students in each group to ensure one-on-one error correction and feedback.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTraining content and process of standardized CPR\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDuration\u003c/p\u003e \u003cp\u003e(min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCore content\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheoretical teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIdentification of cardiac arrest, core steps of CPR (C-A-B), key parameters of chest compression, artificial respiration and AED usage, first aid ethics and laws\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkill demonstration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard operation demonstration with adult CPR manikins, emphasizing palm root positioning, arm straightening and chest recoil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent practical operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 students per group (1 teacher guidance), each student completes 3 sets of complete CPR (30 compressions\u0026thinsp;+\u0026thinsp;2 breaths) with one-on-one error correction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ\u0026amp;A and summary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnswer practical operation questions, sort out core knowledge points and common operation misunderstandings\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: CPR\u0026thinsp;=\u0026thinsp;Cardiopulmonary Resuscitation; AED\u0026thinsp;=\u0026thinsp;Automated External Defibrillator.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Evaluation tools and indicators\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1 Questionnaire design\u003c/h2\u003e \u003cp\u003eReferring to the AHA adolescent CPR assessment tool and domestic relevant studies, a unified paper-based pre and post-training questionnaire was designed with the same structure (16 questions in total), including three dimensions: general information (school type, gender, age), attitude and previous training (5 questions: training necessity cognition, training willingness, training fear, rescue willingness, previous CPR training history), and CPR knowledge (11 questions, full score 10). The knowledge questions covered 10 core points such as chest compression speed, compression position, AED usage timing, and unresponsive choking management (repeated questions on compression position were both answered correctly to get 1 point, otherwise the questionnaire was excluded). The questionnaire used in this study was developed by the authors based on a review of the relevant literature and expert consultation. The full English version of the questionnaire is provided in Supplementary Material 1\u0026ndash;3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2 Evaluation time and quality control\u003c/h2\u003e \u003cp\u003ePre-training test: Completed independently by students before the start of theoretical courses, with on-site verification of completeness; Post-training test: Completed independently by students after the end of practical courses without mutual communication.\u003c/p\u003e \u003cp\u003eQuality control measures: Uniform distribution and recovery of questionnaires by the research team; double entry of data with EpiData 3.1 and logical verification\u0026thinsp;+\u0026thinsp;manual proofreading; unified teaching language and operation standards by the teaching team to avoid teaching deviation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e \u003cp\u003eR 4.3.1 software was used for statistical analysis. Quantitative data (age, total knowledge score) were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\text{x}\\text{\u0026plusmn;}\\text{s}\\)\u003c/span\u003e\u003c/span\u003e), with paired \u003cem\u003et\u003c/em\u003e-test for pre and post-training comparison and independent sample \u003cem\u003et\u003c/em\u003e-test for subgroup comparison. Categorical data (gender composition, attitude/willingness proportion, single question correct rate) were expressed as frequency (percentage), with χ\u0026sup2; test for pre and post-training and subgroup comparison. The test level α\u0026thinsp;=\u0026thinsp;0.05, \u003cem\u003eP\u003c/em\u003e \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Baseline characteristics of the study subjects\u003c/h2\u003e \u003cp\u003eA total of 9525 valid pre-training samples were included, with an average age of 15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42 years (range 15\u0026ndash;17 years). Among them, 6088 girls (63.9%), 3437 boys (36.1%); 7787 vocational high school students (81.8%), 1738 high school students (18.2%); 4473 students with previous CPR training history (47.0%), 5052 without (53.0%). The proportion of students who thought training was \"necessary\" was 99.4%, \"willing to participate\" was 99.1%, \"with training fear\" was 13.7%, and \"willing to perform rescue\" was 88.7%. The total pre-training knowledge score was 5.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03 points (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study subjects (pre-training, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9525)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%/\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\text{x}\\text{\u0026plusmn;}\\text{s}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1738\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7787\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e81.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious CPR training history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognition of training necessity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNecessary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9472\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnnecessary/Unknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining willingness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWilling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnwilling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining fear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e86.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWillingness to perform rescue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e88.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal knowledge score (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: CPR\u0026thinsp;=\u0026thinsp;Cardiopulmonary Resuscitation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSubgroup baseline comparison showed that the pre-training knowledge score of vocational high school students was significantly higher than that of high school students (5.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03 vs 5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and that of girls was significantly higher than that of boys (5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00 vs 5.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePre-training CPR knowledge scores of different subgroups (\u003cem\u003ex\u0026thinsp;\u0026plusmn;\u0026thinsp;s\u003c/em\u003e, points)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubgroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKnowledge score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale (6088)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale (3437)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational high school (7787)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school (1738)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Comparison of CPR knowledge mastery before and after training\u003c/h2\u003e \u003cp\u003eThe total post-training CPR knowledge score was 8.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61 points, which was significantly higher than the pre-training score (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). The correct rate of all 10 core knowledge points increased significantly after training, with an increase range of 14.8% \u0026minus;\u0026thinsp;42.2% (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB-L). The correct rate of \"unresponsive choking management method\" increased the most (35.5% \u0026rarr; 77.7%), and the increase of \"AED usage timing\", \"chest compression depth\" and \"compression position\" exceeded 40% (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the correct rate of core CPR knowledge points before and after training\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCore knowledge point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-training correct rate (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-training correct rate (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIncrease range\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eχ\u0026sup2; value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChest compression speed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2846.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsciousness judgment method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2419.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u0026amp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompression position (inferior sternum)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2287.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeartbeat judgment position (carotid artery)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e93.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1963.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArm posture for chest compression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2798.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCPR compression-ventilation ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e97.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2811.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChest compression depth (adult)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e92.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2568.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAED usage timing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e79.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2089.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnresponsive choking management method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e77.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1976.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGolden time of CPR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2987.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: CPR\u0026thinsp;=\u0026thinsp;Cardiopulmonary Resuscitation; AED\u0026thinsp;=\u0026thinsp;Automated External Defibrillator.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Subgroup analysis of knowledge scores\u003c/h2\u003e \u003cp\u003eAfter training, the knowledge score gap between high school and vocational high school students narrowed from 0.65 point to 0.12 point, and the gender difference in knowledge scores was no longer statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.36). Students with previous CPR training history had a significantly higher pre-training knowledge score than those without (5.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98 vs 5.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the post-training improvement amplitude was more significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Comparison of first aid attitude and rescue willingness before and after training\u003c/h2\u003e \u003cp\u003eAfter training, the students\u0026rsquo; first aid attitude and rescue willingness showed a significant positive change: the proportion of \"willing to help when seeing patients on the road\" increased from 88.7% to 94.3% (χ\u0026sup2; = 213.5, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); the proportion of \"with training fear\" increased slightly from 13.7% to 14.6% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.100, no statistical significance); the proportion of \"thinking training is necessary\" and \"willing to participate in training\" both remained above 99.1%, with no significant pre and post-training differences (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of first aid attitude and rescue willingness before and after training\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-training (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9525) \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-training (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6549) \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognition of training necessity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNecessary: 9472 (99.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNecessary: 6526 (99.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining willingness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWilling: 9441 (99.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWilling: 6489 (99.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.888\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining fear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes: 1306 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 959 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWillingness to perform rescue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes: 8450 (88.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 6176 (94.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e213.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Subgroup analysis of attitude and rescue willingness\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.5.1 School type subgroup\u003c/h2\u003e \u003cp\u003eAfter training, the proportion of \"training fear\" in high school students (10.1%) was significantly lower than that in vocational high school students (15.7%) (χ\u0026sup2; = 41.2, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); the proportion of \"willing to perform rescue\" in high school students (95.2%) was slightly higher than that in vocational high school students (94.1%), with no statistical significance (χ\u0026sup2; = 2.1, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.153); the proportion of vocational high school students with previous CPR training history (60.9%) was significantly lower than that of high school students (70.3%) (χ\u0026sup2; = 47.8, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.5.2 Gender subgroup\u003c/h2\u003e \u003cp\u003eThere was no significant difference in the proportion of \"training fear\" between boys and girls before training (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.699); after training, the proportion of \"training fear\" in boys was slightly higher than that in girls, with no statistical significance (χ\u0026sup2; = 2.6, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.105). The proportion of \"willing to perform rescue\" in girls (65.4%) was slightly higher than that in boys (34.6%) after training, with no statistical significance (χ\u0026sup2; = 3.8, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.052).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study confirmed that hospital-school collaborative standardized CPR training by professional medical teams can significantly improve the CPR knowledge mastery and rescue willingness of 15-17-year-old adolescents in Guangzhou, and effectively narrow the first aid ability gap between different school types and genders, which has important public health significance for optimizing the community emergency \"chain of survival\" and improving the OHCA prognosis.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.1 The \"three-dimensional empowerment\" effect of standardized training\u003c/h2\u003e \u003cp\u003eThe training realizes the collaborative improvement of students\u0026rsquo; knowledge, skills and psychology: in terms of knowledge, the core points with low baseline cognition (AED usage, choking management, compression position) achieved the most significant improvement, which is due to the combination of targeted theoretical explanation and one-on-one practical operation guidance in the training, making up for the deficiency of adolescent\u0026rsquo;s fragmented first aid knowledge acquisition in daily life; in terms of psychology, the rescue willingness increased by 5.6 percentage points while the training fear did not increase significantly, indicating that the standardized practical operation reduced students\u0026rsquo; fear of actual rescue and enhanced their self-efficacy in first aid. This is consistent with the conclusion of Riggs et al [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] that professional medical staff-led training can improve the psychological acceptance of CPR for adolescents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.2 The cumulative effect of previous training history and the necessity of retraining\u003c/h2\u003e \u003cp\u003eStudents with previous CPR training history had significantly higher pre-training knowledge scores and more significant post-training improvement, which confirmed the cumulative effect of CPR training: the initial training lays the foundation of knowledge and skills, and the standardized re-training realizes the consolidation and improvement of abilities. Combined with the existing research that adolescent CPR skills begin to attenuate 3 months after training without retraining [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], it is suggested that a regular retraining mechanism (such as annual re-training) should be established in the follow-up to maintain the long-term effectiveness of training.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e4.3 The balanced improvement effect of subgroup differences and the enlightenment of inclusive training\u003c/h2\u003e \u003cp\u003eThe pre-training knowledge gap between different school types and genders is closely related to their educational background and learning characteristics: vocational high school students have more opportunities to contact practical skills related to first aid due to the practice-oriented curriculum, so their pre-training scores are higher; girls have advantages in theoretical knowledge learning due to their attention to details [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. After training, the gap is significantly narrowed, which is the core value of the standardized and inclusive training model in this study: the unified teaching content and one-on-one guidance make up for the deficiency of high school students in practical operation and boys in theoretical knowledge, realizing the balanced improvement of different groups.\u003c/p\u003e \u003cp\u003eFor school type differences, the follow-up training can adopt the mode of \"universal content\u0026thinsp;+\u0026thinsp;personalized focus\": strengthen the practical scene simulation for high school students, and increase the first aid scene expansion combined with professional courses for vocational high school students (such as ward first aid simulation for nursing major). For gender differences, give play to the complementary advantages of genders: strengthen the guidance of compression position accuracy for boys, and increase the chest compression strength training for girls with the help of elastic bands, so as to realize the maximization of training effect.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e4.4 The promotion value of hospital-school collaboration model\u003c/h2\u003e \u003cp\u003eThe hospital-school collaboration model solves the core problems of adolescent first aid training such as non-professional teachers and inadequate operation guidance: professional medical teams ensure the standardization of training content and operation, and schools provide the carrier and coverage of training, forming a win-win pattern of \"medical resource sinking and school quality education improvement\". The 3-hour training model (1 h theory\u0026thinsp;+\u0026thinsp;2 h practical) in this study is highly compatible with the middle school curriculum arrangement, and is suitable for large-scale promotion in adolescents. At the same time, the 94.3% post-training rescue willingness means that students will become the \"seed group\" of community first aid, and realize the radiation and dissemination of first aid knowledge from \"students to families and communities\", which is of great significance for improving the overall first aid level of the population.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Study limitations\u003c/h2\u003e \u003cp\u003eThis study has certain limitations: first, the sample is limited to urban schools in Guangzhou, and the popularization of the training model in rural and central and western regions needs to be verified by multi-center studies; second, the study lacks a control group, and the potential impact of social first aid publicity cannot be excluded; third, only the short-term effect of training is evaluated, and the long-term retention of CPR knowledge and skills needs to be further tracked by follow-up surveys; fourth, the evaluation indicators are mainly subjective questionnaires, and the combination of objective operation indicators (such as compression depth and speed compliance rate) can make the evaluation more comprehensive.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eHospital-school collaborative standardized CPR training implemented by professional medical teams can significantly improve the CPR knowledge mastery and rescue willingness of 15-17-year-old middle and vocational high school students, effectively narrow the first aid ability gap between different school types and genders, and verify the feasibility and popularization of this model. This model provides a practical intervention path for improving adolescent first aid literacy, perfecting the community emergency \"chain of survival\" and improving the prognosis of OHCA. In the future, it is necessary to build a normalized adolescent first aid training system relying on policy support, improve the long-term effectiveness of training through the establishment of a regular retraining mechanism, and expand the coverage of training to rural and remote areas, so as to provide a solid support for improving the national first aid ability and the level of public health emergency response.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Sun Yat-sen Memorial Hospital, Sun Yat-sen University(Approval No. SYSKY-2024-759-01). Written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization:\u0026nbsp;\u003c/strong\u003eWang Pengfei; \u003cstrong\u003eMethodology:\u0026nbsp;\u003c/strong\u003eWang Pengfei, Song Fengqing; \u003cstrong\u003eFormal analysis:\u003c/strong\u003e Tang Junpeng; \u003cstrong\u003e\u0026nbsp;Investigation:\u003c/strong\u003e Liang Ting;Ye Shunhua; Li Li;Wang Peng; \u003cstrong\u003eData curation:\u003c/strong\u003e Liang Ting, Feng Xiaowei; Zeng Chaotao; \u003cstrong\u003eVisualization \u0026amp; Software :\u003c/strong\u003eTang Junpeng; \u003cstrong\u003eWriting\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e–\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Original Draft:\u003c/strong\u003e Wang Pengfei; \u003cstrong\u003eWriting\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e–\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Review \u0026amp; Editing:\u003c/strong\u003e Yu Tao, Song Fengqing; \u003cstrong\u003eSupervision:\u003c/strong\u003e Liu Wandi.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the medical staff of the Emergency Department of Sun Yat-sen Memorial Hospital of Sun Yat-sen University for their hard work in the CPR training and data collection, and all the participating schools and students in Guangzhou for their active cooperation in this study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of generative AI and AI-assisted technologies in the manuscript preparation process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work, the authors used AI writing tools only for language polishing and structural optimization of the manuscript. After using the tool, the authors reviewed and edited the content in detail, and take full responsibility for the content of the published article. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShao H, Li CS. Epinephrine in Out-of-hospital Cardiac Arrest: Helpful or Harmful? Chin Med J (Engl). 2017;130:2112\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolmberg M, Holmberg S, Herlitz J. The problem of out-of-hospital cardiac-arrest prevalence of sudden death in Europe today. Am J Cardiol. 1999;83:D88\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolmberg M, Holmberg S, Herlitz J. Factors modifying the effect of bystander cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in Sweden. Eur Heart J. 2001;22:511\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen M, Wang Y, Li X, et al. Public Knowledge and Attitudes towards Bystander Cardiopulmonary Resuscitation in China. Biomed Res Int. 2017;2017:3250485.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePivač S, Gradišek P, Skela-Savič B. The impact of cardiopulmonary resuscitation (CPR) training on schoolchildren and their CPR knowledge, attitudes toward CPR, and willingness to help others and to perform CPR. BMC Public Health. 2020;20:915.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatanabe K, Lopez-Colon D, Shuster JJ, Philip J. Efficacy and retention of Basic Life Support education including Automated External Defibrillator usage during a physical education period. Prev Med Rep. 2017;5:263\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShams A, Raad M, Chams N, et al. Community involvement in out of hospital cardiac arrest: A cross-sectional study assessing cardiopulmonary resuscitation awareness and barriers among the Lebanese youth. Med (Baltim). 2016;95:e5091.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeissner TM, Kloppe C, Hanefeld C. Basic life support skills of high school students before and after cardiopulmonary resuscitation training: a longitudinal investigation. Scand J Trauma Resusc Emerg Med. 2012;20:31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsbye DL, Rasmussen LS, Ringsted C, et al. Disseminating Cardiopulmonary Resuscitation Training by Distributing 35 000 Personal Manikins Among School Children. Circulation. 2007;116:1380\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOcampo Cervantes AB, L\u0026oacute;pez L\u0026oacute;pez CA, Cerezo Espinosa C, et al. Virtual reality versus theoretical training in CPR among adolescents: a randomized trial with a one-year longitudinal follow-up. Resusc Plus. 2026;27:101178.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiggs M, Franklin R, Saylany L. Associations between cardiopulmonary resuscitation (CPR) knowledge, self-efficacy, training history and willingness to perform CPR and CPR psychomotor skills: A systematic review. Resuscitation. 2019;138:259\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescents, Cardiopulmonary resuscitation training, First aid literacy, Hospital-school collaboration, Out-of-hospital cardiac arrest","lastPublishedDoi":"10.21203/rs.3.rs-9260068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9260068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo evaluate the effect of hospital-school collaborative standardized cardiopulmonary resuscitation (CPR) training on CPR knowledge, first aid attitude and willingness to perform rescue in 15-17-year-old middle and vocational high school students in Guangzhou, and analyze subgroup differences by school type and gender, so as to provide evidence for constructing a normalized adolescent first aid training model.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA multi-stage cluster sampling method was used to select 11589 students from 9 schools (4 high schools, 5 vocational high schools) in 6 administrative districts of Guangzhou. Standardized CPR training based on the 2020 AHA Guidelines (1 h theory\u0026thinsp;+\u0026thinsp;2 h practical operation\u0026thinsp;+\u0026thinsp;one-on-one guidance) was implemented by professional medical teams. Unified questionnaires were used to assess CPR knowledge (full score 10), first aid attitude and rescue willingness before and after training. R 4.3.1 was used for statistical analysis (paired \u003cem\u003et\u003c/em\u003e-test for quantitative data, χ\u0026sup2; test for categorical data).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 6549 valid post-training samples were included, with vocational high school students accounting for 81.8% and girls 63.9%. The total CPR knowledge score increased significantly from 5.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03 to 8.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The correct rate of 10 core knowledge points increased by 14.8% \u0026minus;\u0026thinsp;42.2%, with the increase of \u0026ldquo;AED usage timing\u0026rdquo;, \u0026ldquo;chest compression depth\u0026rdquo; and \u0026ldquo;unresponsive choking management\u0026rdquo; exceeding 40%. The willingness to perform rescue rose from 88.7% to 94.3% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the proportion of training fear increased slightly from 13.7% to 14.6% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.100). Subgroup analysis showed that vocational high school students had a higher pre-training knowledge score than high school students (5.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03 vs 5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and girls had a higher score than boys (5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00 vs 5.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03). After training, the knowledge gap between the two school types narrowed from 0.65 to 0.12 points, and there was no significant gender difference in knowledge scores (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.36). Students with previous CPR training history had significantly higher pre-training knowledge scores than those without (5.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98 vs 5.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eHospital-school collaborative standardized CPR training by professional medical teams can significantly improve CPR knowledge and rescue willingness of adolescents, and effectively narrow the ability gap between different school types and genders. It provides a practical intervention path for improving adolescent first aid literacy, improving the community emergency \"chain of survival\" and enhancing the prognosis of out-of-hospital cardiac arrest (OHCA).\u003c/p\u003e","manuscriptTitle":"Hospital-school collaborative standardized cardiopulmonary resuscitation training improves first aid literacy in adolescents: A large-sample study in Guangzhou","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-05 20:38:49","doi":"10.21203/rs.3.rs-9260068/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-07T10:08:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T17:11:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242092740570986419261227749666396923496","date":"2026-05-04T16:19:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134664829776744702347334001527925107454","date":"2026-04-24T07:02:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-24T06:35:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-23T08:10:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-04T18:23:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-03T11:34:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-04-03T11:24:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"16ec86e1-e274-4e38-baa8-f89335a30062","owner":[],"postedDate":"May 5th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-07T10:08:21+00:00","index":72,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T17:11:20+00:00","index":70,"fulltext":""},{"type":"reviewerAgreed","content":"242092740570986419261227749666396923496","date":"2026-05-04T16:19:58+00:00","index":68,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T20:38:49+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-05 20:38:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9260068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9260068","identity":"rs-9260068","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}