Widespread effective training in cardiopulmonary resuscitation (CPR) can save countless lives. Nearly 80% of cardiac arrests are witnessed by a family member and occur in one’s home. The survival rate of victims of sudden cardiac arrest may be no more than five percent, because the overwhelming majority of bystanders who witness the event do not know how to perform CPR
]. Less than one-third of victims of sudden cardiac arrest receive CPR from bystanders, and even fewer receive adequate quality CPR
]. Often lay responders, despite having a desire to provide basic life support, lack the skill to correctly provide this service
]. Moreover, training alone may not be enough to ensure that individuals are willing and able to effectively administer CPR
Those who have been trained in CPR may show a decrease in essential knowledge and skills within just a few months after training
]. Further, lack of confidence in conducting CPR
], as well as lack of willingness to attempt it
], may be impediments to intervening in a crisis. Currently the American Red Cross requires individuals to renew their CPR certification annually; this often requires a 4- to 8-hour refresher course. However, it is neither feasible nor cost-effective to conduct frequent in-person recertification courses.
Studies show that frequent refresher courses can help both medical and lay personnel maintain CPR skills
]. Smaller-scale refresher materials, presented to trainees between certifications and re-certifications, could fill in memory and confidence gaps, but only if the effort is made to use them
]. Poster-based refreshers were equally as effective as instructor-led refreshers in relation to skill retention one year post training
]. Moreover, additional training for people previously certified in CPR led to lesser declines over time in willingness to perform CPR
Actual skill is only one of the factors that can make the difference between a passive bystander during an emergency and an effective administrator of CPR. Social-cognitive theory emphasizes that enacting any behavior also depends on a person’s confidence (“self-efficacy”) in performing that behavior and motivation (intent) to perform it
]. Program evaluators have recognized the gap between the acquisition of knowledge or skills and subsequent changes in attitudes and behavior
]. In support of the social-cognitive theory of behavior change, a recent study of motivation, self-confidence and skill retention found that gains in these factors were dependent on the method and timing of CPR training
]. Therefore, an effective CPR refresher must address not only skill retention, but also confidence and behavioral intention to perform CPR. More research is required to examine the effectiveness of CPR refreshers on skill retention, confidence and motivation, as well as the appropriate format, timing and frequency of such refreshers.
In order to be effective, CPR refreshers should be easily accessible, available at no or low cost, and likely to be reviewed by trainees in the general population. Thus, the most desirable format would be to deliver the content to a trainee’s home or office, rather than requiring the person to attend a session in a special location. New electronic means of communication have expanded the possibilities for delivering CPR refreshers to members of the general public who received training in CPR. Such an approach does not include renewed CPR practice, which is difficult to arrange. Our basic assumption was that various electronic modalities can actively direct the attention of prior trainees to messages designed to help them in recalling correct CPR techniques. Specifically, electronic refreshers are hypothesized to aid in retaining CPR administration skills, confidence in performing CPR and intention to perform CPR when needed.
General population access to and use of electronic communication is already quite extensive, especially among younger people, and is continually increasing
]. Studies have documented internet access among even more difficult to reach (e.g., low income) populations
]. Based on these trends of increasing access to electronic and mobile communications, the novel CPR refresher formats selected for this study were: online website, e-mail, and text messaging by cell phone. Recent studies have shown that such electronic communication formats can be effective in increasing confidence and motivation to engage in health promoting behaviors
The present study conducted a randomized controlled trial (RCT) of four CPR refreshers - online website, e-mail, text messaging and a mailed brochure – to determine their efficacy in affecting skill retention, confidence in using CPR and intention to use CPR at a one year follow-up after initial CPR training. The first three refreshers, based on electronic communication, can be considered “novel” in that they are not typically used to refresh CPR knowledge and skills. Print materials, which are often costly to produce, have been the traditional method for delivering many health behavior messages to the home. The mailed brochure is a common health education format that was conceptualized as the control condition for the study.
Correctly recalled and applied CPR steps are essential in lifesaving. Studies have shown that the quantity and spacing of refreshers is related to the degree of subsequent skill retention
]. Thus the present study also tested whether repeating the CPR refresher episodes was useful for proper sequencing of skills in administering CPR.
The primary study hypothesis is that the three novel, technologically “active” CPR refreshers, will yield outcomes superior to those of the relatively passive, traditional mailed brochure refresher. (We do not hypothesize the relative efficacy of the three novel refreshers; this aspect of the analysis is exploratory.) The secondary study hypothesis is that subjects receiving two refresher episodes will have outcomes superior to subjects receiving only a single refresher episode.