RCParvulari training: A basic life support training methodology applied to 5-year-old students:

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www.analesdepediatria.org

ORIGINAL ARTICLE

RCParvulari training: A basic life support training methodology applied to 5-year-old students:

Effectiveness in a cluster-randomized clinical trail

David Pedrazas-López

^a

, Bernat de Pablo-Márquez

^b,^∗

, Oriol Cunillera-Puértolas

^c,d

, Jesús Almeda-Ortega

^c,d

, Grupo de Investigación RCParvulari

¹

aCentrodeAtenciónPrimariaSantAndreudelaBarca,DireccióndeAtenciónPrimariaCostadePonent,InstitutCatalàdela Salut,SantAndreudelaBarca,Barcelona,Spain

bCentrodeAtenciónPrimariaValldoreix,MútuaTerrassa,Valldoreix,Spain

cUnidaddeApoyoalaInvestigacióndeCostadePonent,FundacióInstitutUniversitariperalaInvestigacióenAtencióPrimària JordiGol(IDIAPJGol),CornellàdeLlobregat,Barcelona,Spain

dUniversitatAutònomadeBarcelona,Bellaterra,CerdanyoladelVallès,Spain

Received7February2022;accepted4May2022 Availableonline3February2023

KEYWORDS Cardiopulmonary resuscitation;

Basiclifesupport;

Teachingmaterials;

Primaryeducation;

Knowledge;

School;

Schoolchildren

Abstract

Introduction:Basiclifesupporttraininginschoolageisatopicalissuebecause,withadequate training,anypersoncanhelpsavealife.

Methods:Clusterclinicaltrialwithdatacollectionthroughanadhocself-administered,semi- structured questionnaire. The target populationencompassed the students aged 4---6 years enrolledin49educationalcentres.Thecentreswererandomlyallocatedtotheintervention orcontrolgroup.TheinterventiongroupwastrainedwiththeRCParvulari^® methodology,con- sistingoftheoreticalandpracticaltrainingonthefirstlinkofthechainofsurvival.Thecontrol grouponlyreceivedtheoreticaltraining.Weevaluatedparticipantsbefore andimmediately aftertheinterventionandbetween3and12monthspostinterventionbymeansoftheques- tionnaire.We assessedthe acquisitionandretention overtime oftheknowledge andskills coveredinthetrainingcomparedtoprevioustrainingsinbothgroups.

∗Correspondingauthor.

E-mailaddress:[email protected](B.dePablo-Márquez).

1 GrupodeInvestigaciónRCParvulari:CampíñezNavarro,Manuel(Orewa,NuevaZelanda),delCastilloGiraldez,Ana(SantVicençdels Horts,España),DíazCarrasco,FrancescXavier(Abrera,España),EspinachGarcía,Nèstor(Badalona,España),FernándezCarod,Noèlia(Sant JoanDespí,España),GarcíaFont,David(Abrera,España),FloresCarrillo,Anna(Esparreguera,España),RodaDiestro,Jovita(SantAndreu delaBarca,España),VergèsMacario,Isabel(Abrera,España).

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Results: Atotalof1327schoolchildren(79%ofthetargetpopulation)participated.Thelevel ofknowledgeacquiredimmediatelyaftertrainingandafter3---12monthscomparedtobaseline wassignificantlybetter(P<.001)intheinterventiongroupthaninthecontrolgroup,bothin earlyrecognitionandcontactingofemergencyservices(112)andinrememberingthe‘‘mouth- nose-eyes’’mnemonic.

Conclusions: TheRCParvulari^®methodologysignificantlycontributedtoanimprovedabilityto recognizeapossiblemedicalemergency,startthechainofsurvivalbyalertinganadultandcall the112emergencynumberinstudentsinthelastyearofpreschooleducation.

4.0/).

PALABRASCLAVE Reanimación cardiopulmonar;

Soportevitalbásico;

Materialesde ense˜nanza;

Educaciónprimaria;

Conocimiento;

Escuela;

Escolares

FormaciónRCParvulari:unametodologíadeformaciónensoportevitalbásico aplicadoalalumnadode5a˜nosdeeducacióninfantil:Efectividadenunensayo clínicoaleatorizadoporconglomerados

Resumen

Introducción: Laformaciónensoportevitalbásicoenedadescolaresuntemadeactualidad, yaque,conunaformaciónadecuada,todoindividuopuedeayudarasalvarunavida.

Métodos: Ensayoclínicoporconglomeradosbasadoenuncuestionarioadhoc,autoadministra- bleysemiestructurado.Lapoblacióndianafueronalumnosdeentre4y6a˜nosde49centros educativos. Loscentros sealeatorizaronengrupo intervenciónycontrol.Elgrupointerven- ciónrecibiólametodologíaRCParvulari^®,consistenteenunaformaciónteórico-prácticasobre elprimer anillodelacadenade supervivencia.Elgrupocontrolsolorecibióunaformación teórica.Lossujetosdeestudiofueronevaluadospre-intervención,post-intervenciónyentre3 y12despuésmedianteuncuestionario.Sevaloróadquisiciónyretenciónalolargodeltiempo delainformaciónrecibida,encomparaciónconlaformaciónpreviaenambosgrupos.

Resultados: Participaronuntotalde 1327escolares(79%de lapoblacióndiana).Elnivelde conocimientos adquiridos inmediatamente después de la formación y pasados 3---12 meses aumentómásrespectoalbasalenelgrupointervenciónqueenelgrupocontrolcondiferencias significativas(P<,001),tanto alreconoceryllamar alnúmerodeemergencias112,comoal recordarlamnemotecnia‘‘boca-nariz-ojos’’.

Conclusiones: La metodología RCParvulari^® contribuyó de forma significativa a mejorar la capacidaddelalumnadode5^◦cursodeeducacióninfantilparareconocerunaeventualemer- genciamédica,ponerenmarchalacadenadelasupervivenciaalertandoaunadultoyllamando alnúmerodeemergencias112.

Introduction

Out-of-hospital cardiac arrest (OHCA)is the third-leading causeofdeathindevelopedcountries¹anditiswitnessedby relatives,friendsorotherbystandersinupto70%ofcases.² Earlycardiopulmonaryresuscitationisadeterminingfactor forsurvivalandneurologicalotucomes.³Thebasic corner- stoneofrespondingtoOHCAistraininginbasiclifesupport (BLS)and,inthis regard,trainingschoolchildrenisone of themosteffectivestrategies.^4,5

The chain ofsurvival (CS) wasproposed by theAmeri- canHeartAssociation(AHA)in1991andhasbeenevolving tothisdaywiththecollaborationoftheAHAandtheEuro- peanResuscitationCouncil(ERC).^1,2Itconsistsofaseriesof actionsaimedatsavingthelivesofvictimsofcardiacarrest.

These actionsrangefromearly recognitionandactivation ofemergencyservices(thefirstlinkofthechainofsurvival)

todeliveryofadequatecardiopulmonaryresuscitationand earlyuseofthedefibrillator.

Despite the fact that the Kids Save Lives statement³ issuedbytheERCandendorsedbytheWorldHealthOrgani- zationrecommendsteachingcardiopulmonaryresuscitation (CPR)toschoolchildrenfor2hperyearfromage12,⁴there isevidencethatshows thatthechainofsurvivalsequence canbelearnedfromage6years.⁵ Ingeneral,BLStraining programsarenotincludedintheearlychildhoodeducation orprimaryeducationcurriculainSpain.^1,6---8

Althoughrandomizedcontrolledtrialshaveinvestigated theeffectofaBLSworkshopinprimaryschool⁹andmedical school,¹⁰thereislessevidenceforchildrenaged5---8years.

Severalstudiessuggest thatschoolchildrenaged5---8years retainwhattheyhavelearnedwell,andevaluationresults arenotinferiortothoseinolderchildrenoradults.^1,8Some studieshaveevenshownthat childrenaged5---8yearsare 100

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abletounderstandthechainofsurvivalandhowtoactivate it,^1,11---13 although theimpactofBLStrainingattheseages hasnotbeen evaluated. Infact,todate,thereis novali- datedquestionnairedevelopedtoassessknowledgeonBLS inyoungchildren.

Thepurposeofourstudywastoassesstheacquisitionand retentionovertimeofBLSknowledgeandskills(mainlythe firstlinkinthechainofsurvival)inschoolchildreninthelast yearofpreschooleducationtrainedwithanovelCPReduca- tionmethodology(RCParvulari^®)comparedtostandardBLS training.¹⁴

Methods

Studydesign

Weconductedaclusterrandomisedcontrolledclinicaltrial.

Studypopulation

Thetargetpopulationcomprisedthe1680studentsofyear P-5(lastyearofpreschooleducation,withanagerangeof 4---6 years)enrolled inthe49 earlychildhoodandprimary educationschoolsbasedonthemunicipalpopulationcensus of2016.¹⁵

Schoolswhoseadministratorsagreedtoparticipateinthe studywererandomlyassignedtotheinterventionorcontrol group(clusterrandomizationwitharandomnumbertable).

Theinclusioncriteriawerecurrentenrolmentinthepar- ticipating early childhood and primary education schools duringthestudyperiodandsignedinformedconsenttothe child’sparticipationfromtheparentsorlegalguardians.

Intervention

The intervention group (IG) was trained with the RCParvulari^® methodology, in which knowledge and skills related to the first link of the chain of survival are taught with different modalities (drawings, photographs, songs,roleplayactivitieswithgiantmobilephonemodels) withbrief,changing,participatoryandrepetitiveactivities (Fig.1),withanoveralldurationofapproximately45min.

Thisinterventionhasbeendescribedinapreviousarticle.¹⁴ The controlgroup(CG)receivedonlytheoreticaltrain- ingontheconceptsandskillsinthefirstlinkofthechainof survival.The trainingwasstructuedaroundaPowerPoint^® presentationthatincludedtheoreticalconcepts,algorithms and imagesthat explained that in the eventof an emergency,onehadtocalltheemergencynumber112,andthe mnemonic: mouth-nose-eyes. The traininglasted approxi- mately30min.

Studyvariables

Toassessthevariablesunderstudy,wedevelopedanadhoc self-administered and semi-structured questionnaire. The questionnaire was drafted and underwent validity assess- ment and a pilot test in 5 students in the age range of interest to ensure that the test wasappropriate for that agegroup.¹⁴

All participants, whether they were in the IG or CG, completed the same questionnaire in the classroom at 3 timepoints:preintervention(justbeforethetraining),post- intervention(immediatelyafterthetraining)andfollow-up (3---12monthsafterthetraining).Fig.2presentsaflowchart withthedistributionintogroupsandthephasesofthestudy.

Thevariablesunderstudywere:

• Dependentvariables:learning(orlackthereof)andunder- standingthefirstlinkinthechainofsurvival,recognising (ornot)emergencynumber112andassociatingit(ornot) withthemouth-nose-eyesmnemonic.¹⁴

• Independentvariables:age,sex,previousBLStrainingand

‘‘gossipeffect’’.

Gossipeffect:whenthequestionnairewasadministered, somechildrencopiedfromthepersonsittingnexttothem.

This eventwassupervised andrecorded by both teachers duringthetimethatstudentswerefillingoutthequestion- naire.

Samplesize

We calculated that it would take 453 in the intervention group and 453 individuals in the control group to detect adifferencegreater or lessthan 10%in theproportionof correctanswersexpectedinthecontrolgroup(0.5,witha minimumrelativeriskof1.2)withanalphariskof0.05and abetariskof 0.2.Weassumedan attritionof10% usinga Poissonapproximation.

Cluster randomization produced a larger sample than required,ensuringadesigneffectof2.Inotherwords,the finalnumberofparticipantspergroupwas906,addingtoa totalsampleof1816.

WeperformedthecalculationswiththeGRANMO^®sample sizecalculator,version7.12(April2012).

Statisticalanalysis

Weperformedcomparative,univariateandbivariateanaly- sesofpreinterventiondataintheinterventionandcontrol groups.Wealsoconductedabivariateanalysisofoutcome variablesbasedonthegroup.Quantitative variableswere expressedasmean andstandarddeviation (SD)or median andinterquartilerange,andqualitativevariables asabso- luteandrelativefrequencies.Tocomparegroups,weused theMann-WhitneyUtestandtheStudentt-testwereused for quantitative variables and the ␹² test for qualitative variables.Wedefinedstatisticalsignificanceasatwo-tailed P value of less than .05. Wefitted 4multivariate logistic regressionmodelsforeachoftheoutcomemeasuresatthe differenttimepoints;inthesemodels,knowledgewasthe dependentvariabletobeexplainedbasedontheinterven- tiongroup,sex,age,previoustraining,previousknowledge ofthe112numberandthemnemonicrule(separately)and thebaselineandfollow-up‘gossip’effects.Themodelswere developedthroughbackward stepwiseregression, starting withthesaturatedmodelandremovingvariablesuntilonly thosethatexplainedthevarianceintheoutcomewereleft, applyingtheAkaikeinformationcriterion.

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Figure1 Giantmobilephonemodelsusedinsimulation(left)androleplaygames(right)intheRCParvulari^®trainingmethod.

The analyses wereperformed withthe statistical soft- wareR,version4.0.5.

Ethicalconsiderations

The studyprotocolwasapprovedbythecompetentethics committee.

TheclinicaltrialwasregisteredinClinicalTrials.govwith identifierNCT03443167.

We obtained signed informedconsent for participation andfordisseminationofstudyimagesfromtheparentsor legalguardiansofallparticipants.

Oncethestudywascompleted,theRCParvulari^®training wasofferedtoallschoolsthat participatedin thecontrol groupandprovidedtothosethatrequestedit.

Results

Forty-oneearlychildhoodandprimaryeducationschoolsin Baix Llobregat agreed to participate in the study, with a cumulativestudentbody of 1327P-5 students; 20schools wereassignedtotheIGand21totheCG(Fig.2).Theresul- tingsampleincluded1327schoolchildren(79%participation rate:746 participants inIG and581 inCG). Ofthis total, 75.2%were5yearsold,and51%(n=648)werefemale.

In thepreintervention evaluation, 14.6%of thesample alreadyknew the112emergencynumber,and10 children (0.8%)reportedknowingthemouth-nose-eyesmnemonic.In thecontrolgroup,amuchhigherproportionknewthe112 number(21.3%comparedto9.3%inIG;P<.001).Inthetotal sample31.6%ofchildrenhadreceivedprevioustrainingon BLSfromthelocal/regionalpoliceorfiredepartment:241in thecontrolgroupand160intheinterventiongroup(42.9%

ofCGvs22.6%ofIG;P<.001)(Table1).

In thepost-intervention evaluation,both groups exhib- itedsignificantchangesintheknowledgeofthe112number and the mnemonic, with greater improvement in the IG (P<.001)(Table1),differencesthatweresustainedinthe follow-up evaluations at 3---12 months, where 71.4% still rememberedthe112numberand19.0%themnemonicrule in the intervention group, compared to 52.7% and 1.0%, respectively,inthecontrolgroup(P<.001)(Table1).

Intheoriginalstudydesign,thefollow-upevaluationhad tobecarriedout6monthsaftertheintervention.¹⁴Insome

schools,thefollow-upevaluationwasdelayedtoupto1year postinterventionduetoorganizationalchallenges.Inspite ofthis,theresultsshowedthatstudentsintheintervention grouprememberedthe112numberandthemnemonicnot onlyforafewmonths,butevenafter1year.

Theresultsofthemultivariateregressionmodelsshowed that the intervention had a statistically significant effect onknowledge of the 112 number and the mnemonicrule immediatelyafterthetrainingandinthefollow-up(P<.001) (Tables2and3),withamorethan20-foldincreaseinthe oddsof knowingthe 112 numberandthe mnemonicrule, withtheexceptionofknowingthe112numberinthefollow- up(theoddsratioofknowingthe112numberinthefollow- upintheinterventiongroupwas3.22).

Other variables, such as prior knowledge and the gossipeffect,werealsosignificantlyassociatedwithacquired knowledge in the multivariate models, depending on the outcomemeasureandthetimingoftheevaluation.

Discussion

TheRCParvulari^®methodisanoveltrainingapproachaimed atchildreninthelastyearofpreschooltomakethemable toactivate the chain of survival in the event of a medi- calemergency.This isachievedby adaptingexistingtools to the age of the students to facilitate their learning: a Power Point^® presentation, a screening of drawings, car- toons,photographs,asongandroleplaywithgiantmobile phonemodels(Fig.1).¹⁴

The results showed that a training lasting 30−50min, withaneminentlypracticalandparticipatoryapproach,sig- nificantlyimprovedknowledgeandpracticesrelatedtothe firstlinkofthechainofsurvivalinchildreninthelastyear ofpreschooleducation.

Toourknowledge,therehavebeennopreviousstudiesin thepreschoolsettingthatmadeaquantitativeassessment ofthelearningcapacityforBLS(theoreticalandpractical) ofchildrenaged4---6years.

There have been previous works, suchasthe study by Martinez-Isasietal.,¹⁶whichshowedthat,afteraperiodof trainingimplementedduringschoolhours,studentsinyears 3and5ofprimaryeducationandyear1ofcompulsorysec- ondaryeducation(aged8---12 years)wereabletoactivate thechainof survivalandinitiate CPR.Similartowhatwe

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Figure2 Flowchartpresentingthedistributionofparticipantsintogroupsandthephasesofthestudy.

didinourstudy,otherauthors,suchasOtero-Agraetal.,¹ haveappliedtheirowntrainingmethodology,validatingthe contentandsuitabilityofthematerialusedintheprocess, totrainolderschoolchildrenonthechainofsurvival.

AlltheseworksshowthatBLStrainingintheschoolset- ting improves knowledge on the subject in the different agegroups targetedin theresearch.This typeof training canhaveagreatimpactonpublichealth,asindividualsof

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Table1 Summaryofresultsbygroupandstudyphase.

Childrenin analysis,n

Missing Total Controlgroup (n=581)

Intervention group (n=746)

P

PRE-INTERVENTIONEVALUATION

Knew112 1262 65 <.001

No 1078(85.4%) 436(78.7%) 642(90.7%)

Yes 184(14.6%) 118(21.3%) 66(9.3%)

Knewmnemonic 1261 66 .946

No 1251(99.2%) 549(99.1%) 702(99.3%)

Yes 10(0.8%) 5(0.9%) 5(0.7%)

Previoustraining 1271 56 <.001

No 870(68.5%) 321(57.1%) 549(77.4%)

Yes 401(31.5%) 241(42.9%) 160(22.6%)

Gossipeffect 1260 67 <.001

No 1069(84.8%) 407(73.6%) 662(93.6%)

Yes 191(15.2%) 146(26.4%) 45(6.4%)

POST-INTERVENTIONEVALUATION

Knew112 1240 87 <.001

No 387(31.2%) 250(46.9%) 137(19.4%)

Yes 853(68.8%) 283(53.1%) 570(80.6%)

Knewmnemonic 1260 67 <.001

No 875(69.4%) 529(95.5%) 346(49%)

Yes 385(30.6%) 25(4.5%) 360(51%)

Gossipeffect 1267 60 <.001

No 954(75.3%) 256(46.2%) 698(97.9%)

Yes 313(24.7%) 298(53.8%) 15(2.1%)

FOLLOW-UPEVALUATION

Knew112 1028 299 <.001

No 366(35.6%) 182(47.3%) 184(28.6%)

Yes 662(64.4%) 203(52.7%) 459(71.4%)

Knewmnemonic 1030 297 <.001

No 904(87.8%) 382(98.9%) 522(81.1%)

Yes 126(12.2%) 4(1.1%) 122(18.9%)

Gossipeffect 1034 293 .056

No 1028(99.4%) 382(98.7%) 646(99.8%)

Yes 6(0.6%) 5(1.3%) 1(0.2%)

Timeoffollow-upinterview 1012 315 <.001

<4months 520(51.4%) 223(58.5%) 297(47.1%)

4---7months 208(20.5%) 57(15%) 151(23.9%)

8---12months 120(11.9%) 25(6.6%) 95(15.2%)

>1year 164(16.2%) 76(19.9%) 88(13.9%)

any agecansave lives iftheyreceive propertraining.³ In addition,earlychildhoodeducationstudentsareopentobe trainedonBLSandcanserveasCPRmultipliersbyteaching theirfriendsandfamilies.¹⁶

Thus, in the long-term, BLS training strategies can increasesurvivalratesandqualityoflifeinvictimsofcardiac arrest.¹⁸ Currently, in Europe, the highest bystander CPR ratesarefoundinScandinaviancountrieswhereeducation ofschoolchildreninCPRhasbeenmandatoryfordecades.³

Basiclifesupporttraininginearlychildhoodisastrategy that can help reduce the mortality associated to out-of- hospitalcardiacarrest.Schoolsaretheidealsettingtoteach BLSiftheobjectiveistotraintheentirepopulation,asit wouldensurethatnearly100%ofthe populationindevel- opedcountrieswouldreceivethetraining.^18,19

EducatingandtrainingchildreninCPRalsobringssocial benefits,sincetheylearntohelpotherpeople.Studentsand teachersarealsoimportantmultipliersandcanincreasethe proportionofindividualstrainedinCPRinthelongterm.^3,17 Onefindingofthisstudyconcernedthevariableadapted from the previous literature that we referred to as the

‘‘gossipeffect’’. Thestudentsansweredthequestionnaire intheir usualenvironment, seatedin theirchairsat their deskintheclassroom.Wenoticedthatatthetimeofcom- pletingthequestionnairebeforetheintervention,children whodid notknow howtoanswer copied frompeers who did.Thisexchangeofinformationisanotherwayoflearn- ing,astheynolongercopiedanswerswhencompletingthe questionnaireimmediatelyaftertheinterventionorinthe follow-up.

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AnalesdePediatría98(2023)99---108 themnemonic.Resultsforthefullmodelarepresentedfirst,followedbyresultsforthemodelobtainedthroughbackwardstepwiseregressionusingtheAkaikeinformation criterion.

112 Mnemonic

Fullmodel Maximumlikelihoodmodel Fullmodel Maximumlikelihoodmodel

OR(95%

CI)

P OR(95%

CI)

P OR(95%

CI)

P OR(95%

CI)

P Independentterm 0.05

(0.01−0.4)

.004 0.10

(0.06−0.15)

<.001 0.01

(0.00−0.05)

<.001 0.01 (0.00, 0.06)

<.001

InterventionGroup 38 (24.3−62)

<.001 37.5 (24−61)

<.001 28.2

(16.2−52.9)

<.001 22.2 (14.5−35.4)

<.001

Malesex 1.1

(0.8−1.6)

.418 1.3

(1−1.7)

.065 1.3

(1−1.7)

.065

Age 1.1

(0.8−1.6)

.583 1.3

(0.9−1.8)

.139 1.3

(0.9−1.8)

.126 Previoustraining 1

(0.7−1.5)

.838 1

(0.7−1,5)

.809 Baselinegossip

effect

0.7 (0.4−1.3)

.223 0.5

(0.2−0.9)

.028 0.5

(0.3−1)

.043 Knew112

previously

3.4 (1.8−6.6)

<.001 2.8

(1.6−5.1)

<.001 2

(1.1−3.5)

.012 2

(1.2−3.5)

.011 Knewmnemonic

previously

0.6 (0.1−3.3)

.504 4.4

(0.9−22.8)

.074 4.6

(0.9−23.6)

.064 Post-intervention

gossipeffect

65.8 (36.9−122.3)

<.001 59.9 (34.9−107.2)

<.001 1.6

(.8−3.1)

.188 CI,confidenceinterval;OR,oddsratio.

105

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D.Pedrazas-López,B.dePablo-Márquez,O.Cunillera-Puértolasetal.

themnemonic.Themodeladjustedforallthevariablesispresentedfirstandthenthemodelresultingfromthe‘‘stepwisebackwards’’variableselectionprocessbasedon

‘‘AkaikeInformationCriteria’’.

112 Mnemonic

Fullmodel Maximumlikelihoodmodel Fullmodel Maximumlikelihoodmodel

OR(95%

CI)

P OR(95%

CI)

P OR(95%

CI)

P OR(95%

CI)

P

Independentterm 0.1

(0.01−0.5)

.006 0.1

(0.01−0.4)

.005 0.01

(0.00, 0.08)

<.001 0.01 (0.00−0.01)

<.001

Interventiongroup 3.2 (2.4−4.4)

<.001 3.2

(2.4−4.4)

<.001 24.6

(10−81.9)

<.001 24

(9.9−79.3)

<.001

Malesex 0.9

(0.7−1.1)

.329 0.9

(0.6−1.3)

.616

Age 1.3

(0.9−1.9)

.116 1.3

(0.9−1.9)

.117 1.0

(0.6−1.6)

.985 Previoustraining 1.4

(1−2.2)

.067 1.4

(1−2.1)

.072 1.3

(0.8−2.3)

.315 Baselinegossipeffect 2.6

(1.3−5.3)

.008 2.3

(1.4−4)

.001 1

(0.4−2.3)

.923 Knew112previously 0.9

(0.5−1.6)

.693 2

(1−3.7)

.034 2.1

(1.2−3.7)

.008 Knewmnemonic

previously

0.9 (0.04−24.5)

.969 0.0

(0.00, Inf)

.991

Interviewperiod(ref.

6months)

<4months 3.8

(2.6−5.5)

<.001 3.7

(2.5−5.4)

<.001 1.4

(0.8−2.7)

.234 1.6

(0.9−2.9)

.114

4−7months (ref.) --- (ref.) --- (ref.) --- (ref.) ---

8−12months 2.8

(1.7−4.7)

<.001 2.8

(1.7−4.6)

<.001 3.5

(1.8−7)

<.001 3.4

(1.8−6.7)

<.001

>1year 2.3

(1.4−3.8)

.001 2.22

(1.4−3.7)

.002 1.5

(0.7−3.1)

.323 1.6

(0.7−3.2)

.229 Post-intervention

gossipeffect

Inf(0.00, Inf)

.968 Inf(0.00,

Inf)

.968 0.00

(0.0−85)

.982 CI,confidenceinterval;OR,oddsratio.

106

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Therearestudies,suchastheonebySekietal.,²⁰that, although carried out in a different setting and in adults, describe‘‘gossip’’asawayofpromotingcooperation,altru- ismandknowledgeretention.

Limitations

Oneofthestrengthsofourstudy,thecreationandevalua- tionofamethodforBLStraininginanagegroupinwhichno researchhadbeenconductedtodate,isalsooneofitslimi- tations:theRCParvulari^®methodologyhasbeencreatedand testedin childreninthe lastyear ofpreschooleducation, sowedonotknowwhetheritwouldbevalidforotherage groups.Wealsocouldnotassesswhethertrainingatanearly agewouldfacilitate theconsolidationofknowledgeabout BLSatlaterages,orwhetheracquisitionofthisknowledge inthisagegroupwouldimprovelong-termsurvivalinvictims ofOHCA.

Another possible limitation of the study is the signifi- cantdifferenceswe foundinpriorknowledgeandtraining betweentheinterventionandcontrolgroups.Althoughthe results support the conclusions, they could not be fully explainedinrandomisedgroups.Itispossiblethatthiswould nothavebeenanissueiftheinitialgroupshadmorehomo- geneouscharacteristics,butthestudydesignwasbasedon theprincipleofrandomization.

Conclusion

Theoretical/practical training using an age-appropriate methodologyhelpsstudentsinthelastyearofearlychild- hoodeducationlearnandretainknowledgeaboutthefirst linkinthechainofsurvival.Theresultsofourstudyshow that basic life support training could be started in early childhoodwithgoodresults.

Conflict of interest

Theauthorsdeclarethattheyhavenoconflictofinterest.

Acknowledgements

Wethankallthechildrenenrolledinyear5ofearlychild- hood education in early childhood and primaryeducation schoolsinBaix LlobregatNordfortheirdailywork andfor selflessparticipationintheproject.Wealsothankthepar- entsofallparticipatingstudentsforbelieving andtrusting intheproject.

Ourappreciationalsoextendstotheadministrativestaff at participatingschoolsfor thelogisticalsupportprovided duringthemonthsoffieldwork.

Lastly, we thank the staff of the Costa dePonent Pri- maryCareAdministrationfor thetranslationandthestaff oftheInstitutUniversitarid’InvestigacióenAtencióPrimària JordiGol IDIAPfortheir support.Also,SaraTorresfor the photographs that she took disinterestedly for the project materials,andEduPérezfordesigningthelogosandposters createdspecificallyfortheRCParvulari^® project.

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