Resuscitation (2007) 75, 169175

TRAINING AND EDUCATIONAL PAPER

Teaching basic life support to school children

using medical students and teachers in a
peer-training modelResults of the
ABC for life programme
P. Toner a, M. Connolly b, L. Laverty c, P. McGrath c,
D. Connolly d, D.R. McCluskey e,
a

Craigavon Area Hospital, United Kingdom

Antrim Area Hospital, United Kingdom
c Queens University Belfast, United Kingdom
d Centre for Clinical Population Sciences, Royal Victoria Hospital,
Belfast, United Kingdom
e Division of Medicine & Therapeutics, Queens University Belfast, Institute of Clinical Science,
Grosvenor Road, Belfast BT12 6BJ, United Kingdom
b

Received 15 January 2007 ; received in revised form 12 March 2007; accepted 19 March 2007
KEYWORDS
Basic life support (BLS);
Cardiopulmonary
resuscitation (CPR);
Education;
Manikins;
Schools

Summary
Background: The ABC for life programme was designed to facilitate the wider
dissemination of basic life support (BLS) skills and knowledge in the population. A
previous study demonstrated that using this programme 1012-year olds are capable
of performing and retaining these vital skills when taught by medical students. There
are approximately 25,000 year 7 school children in 900 primary schools in Northern
Ireland. By using a pyramidal teaching approach involving medical students and
teachers, there is the potential to train BLS to all of these children each year.
Aims: To assess the effectiveness of a programme of CPR instruction using a threetier training model in which medical students instruct primary school teachers who
then teach school children.
Settings: School children and teachers in the Western Education and Library Board
in Northern Ireland.
Methods: A course of instruction in cardiopulmonary resuscitation (CPR) the ABC
for life programme specically designed to teach 1012-year-old children basic
life support skills.

A Spanish translated version of the summary of this article appears as Appendix in the nal online version at
10.1016/j.resuscitation.2007.03.009.
Corresponding author. Tel.: +44 2890 632707; fax: +44 2890 329899.
E-mail address: d.mccluskey@qub.ac.uk (D.R. McCluskey).
0300-9572/$ see front matter 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2007.03.009

170

P. Toner et al.
Medical students taught teachers from the Western Education and Library Board area
of Northern Ireland how to teach basic life support skills to year 7 pupils in their
schools. Pupils were given a 22-point questionnaire to assess knowledge of basic life
support immediately before and after a teacher led training session.
Results: Children instructed in cardiopulmonary resuscitation using this three-tier
training had a signicantly improved score following training (57.2% and 77.7%, respectively, p < 0.001).
Conclusion: This study demonstrates that primary school teachers, previously trained
by medical students, can teach BLS effectively to 1012-year-old children using the
ABC for life programme.
2007 Elsevier Ireland Ltd. All rights reserved.

Introduction

Aims and objectives

Better outcomes have been associated with cardiac

arrests occurring in a public place compared to
a private location, which is thought to be due to
earlier initiation of cardiopulmonary resuscitation
(CPR).1 Bystander CPR is associated with increased
chance of survival,2 with a two-fold increase in
survival rate shown when CPR was performed by
laypersons.2,3
CPR training for school students was rst introduced in Norway in the 1960s.4 In order to target
as many young people as possible, others have
suggested that a CPR training programme should
be included in the school curriculum.57 We have
demonstrated previously that using our training
methods, 1012-year-old children can both acquire
and retain this knowledge for at least 6 months
when taught by medical students.8 Other studies
have shown that children are capable of learning
CPR5,6,911 with effective learning achievable in
children as young as 6 or 7 years of age.10 Teachers have been used to train pupils successfully in
CPR5,6,9 and schools may provide the perfect environment for retraining, thus ensuring retention of
knowledge.6,11
Wik et al. demonstrated that a peer-training
pyramidal approach is effective in training CPR to
a large number of lay people.12 Using a threetier model, lay people (tier 1) were trained as
CPR instructors. Subsequently they trained fellow
employees (tier 2) who in turn trained their family
members in CPR skills (tier 3). Tier 3 trainees were
equal to, if not better than a traditionally trained
group.
The ABC for life programme was developed
to introduce BLS training into primary schools in
Northern Ireland.8 It uses a peer-training model of
medical students who instruct teachers in basic life
support (BLS). The teachers then train the year 7
primary school children in their schools.

To determine the effectiveness of our programme of

instruction using a three-tier peer-training model in
which medical students teach primary school teachers who then instruct primary school children.

Methods and study design

Methods
The ABC for life programme is a course in BLS
training used in Northern Ireland (NI) and specifically designed for 1012-year-old children. The
design of the programme has previously been
described.8 Briey, medical students from Queens
University, Belfast are trained by cardiac resuscitation ofcers from a major teaching hospital to
act as instructors in BLS. Each medical student
subsequently instructs small groups of teachers in
BLS (ratio 1:5, respectively) using the resuscitation guidelines 2000. The teachers are issued with a
manikin, given ancillary teaching materials including a CD-ROM with video clips and teaching aids
so that they can instruct the year 7 pupils in their
schools in small group training sessions. Repetition
of this process results in large numbers of children
being trained in BLS skills over a period of 69
months.

Study design
Teachers, recruited from 38 schools within the
Western Education and Library Board area of NI,
were trained by medical students to be instructors
in BLS and provided with a standard Little Anne
manikin (Laerdal Medical, Norway). Within a period
of 3 months, each teacher began training pupils at
their school. Five children who were selected from
the class register using random number selection

Results of the ABC for life programme

171

Table 1 Effect of sex, family history of cardiac disease and previous basic life support (BLS) training on baseline
score and nal score following training
Sex
Number (%)a
Baseline score (%)
Final score (%)
Difference (%)
a
b

Family history of cardiac disease

Previous BLS training

Male

Female

Yes

No

Yes

No

29 (35.4)
59.1
75.9
16.8b

53 (64.4)
55.4
79.1
23.7b

25 (31.6)
57.3
79.1
21.8

54 (68.4)
57.7
77.7
20

6 (7.3)
64.5
76.4
11.9

76 (92.7)
56.8
77.7
20.9

Numbers do not add to 85 due to missing data.

p < 0.05, t-test.

were trained at each school. Parental consent was

obtained for all children. A 22-point questionnaire
was used to assess pupils knowledge of the main
teaching points (Appendix A) before and after training. Information on age, gender, family history of
heart disease and previous CPR training was also
obtained. The questionnaires were scored by one
investigator who was blinded to the training status
of the pupils.
Statistical analysis was performed using the
12.0.1 SPSS package (Statistics Package for Social
Sciences, Chicago, IL, USA) with changes in knowledge assessed using Students t-test; p < 0.05 was
taken as being signicant.

Results
Thirty-eight teachers from different primary
schools each taught BLS to ve year 7 pupils.
These 190 children were asked to complete questionnaires before and after training. Of these,
questionnaires were returned from 85 (44.7%)
pupils at baseline and 80 (42.1%) pupils after
training. Mean age was 10.7 years with 35% male
and 65% female. Baseline score or score following
training was not affected by gender, positive family
history of heart disease or previous BLS training.
However, male pupils had a smaller increase in
knowledge following training as compared to
female pupils (Table 1).
No pupil achieved full marks on the questionnaire prior to training however nine pupils
(10.6%) scored over 70% (16/22) correct. After
training, one pupil (1.3%) obtained full marks with
55 (68.9%) scoring greater than 70%. Thirty-four
(40.0%) children scored 50% or less before training,
in comparison to only one (1.3%) after training. The
score distribution at baseline and following training
is shown in Figure 1. Following training, there was a
signicant improvement in knowledge was observed
in 15 questions (p < 0.05). There was no change in
seven questions (Q5, 6, 7, 8, 9, 18 and 20). Mean

baseline scores improved after training from 57.2%

to 77.7% (20.5% increase, p < 0.001).

Discussion
This study clearly demonstrates that, using the ABC
for life training programme, primary school teachers who had been trained by medical students can
signicantly improve the understanding of the principles of basic life support skills in 1012-year-old
children.
A recent study of the education and logistical
characteristics of a school-based BLS programme7
showed that of the surveys returned, greater than
80% felt that a CPR programme in schools would
be welcomed by staff, students and parents, and
were highly interested in incorporating a CPR programme into their schools. Respondents felt that
this could save lives and help students deal with
emergencies. Head teachers also felt that theoretical and practical classes should take place in
schools rather than hospitals (95% and 72%, respectively). Although they considered that healthcare
providers rather than school teachers should be in
charge of the theoretical and practical classes (77%
and 97%, respectively), 69% of head teachers would

Figure 1 Score distribution at baseline and after training.

172
be willing to teach CPR theory in their schools if
staff were trained in advance.7
After inviting all of the 900 primary schools in
Northern Ireland to participate in the ABC for life
programme, 450 schools enrolled and at present we
have trained and provided manikins and resource
packs to 250 schools. This suggests that head teachers of primary schools in Northern Ireland are also
eager to incorporate a BLS training programme into
their schools.
One or two teachers from each of the schools
enrolled in the ABC for life programme attend
a 2 h training session and receive a Laerdal Little Anne manikin and resource pack including
an instructional CD-ROM free of charge. These
resources remain in the school and can be used for
training sessions and refresher courses when convenient. They also have access to a dedicated website
www.qub.ac.uk/abcforlife which has the teaching
manual, downloads of teaching aids and training
video clips.
Wik et al. demonstrated previously that a pyramid approach to BLS teaching, similar to that of
the ABC for life programme is less expensive, less
time consuming, simplied, informal and exible.12
Reported barriers to a CPR training programme in
schools include lack of teacher training, lack of
facilities, insufcient time and cost.7,1316 ABC for
life overcomes many of these barriers by providing
all training and resources free of charge.8
We have shown previously that year 7 school children trained directly by medical students retain
the knowledge they acquire for at least 6 months.
We would suggest that the frequent use of training
material in the school and access to all of the teaching aids would allow both the teachers and pupils
to develop their skills and knowledge further and
enhance retention.

P. Toner et al.
While others have indicated that head teachers
would favour health workers training their pupils,7
we feel sure that provided the teachers are properly
trained, from an educational perspective it is best
for professional educators to facilitate the transfer of BLS skills and knowledge to their pupils in a
familiar learning environment.
Ideally BLS training should be part of both the
primary and secondary school curriculum to ensure
that a large proportion of the population are competent in life saving techniques and as a result
reduce the mortality rates from cardiac arrest in
the community.

Conclusion
The ABC for life programme is a three-tier peertraining model which uses a pyramidal approach to
training basic life support to school children. Using
this scheme primary school teachers can deliver
an effective course of instruction to 1012-year
olds in 2 h, small group, training sessions. Provision of a training manual, manikin, instructional
CD-ROM and access to video clips via a dedicated
website allows the professional educators to train
their 1012-year-old pupils in the school environment. This three-tier model of pyramidal training
using medical students and teachers would be the
most cost effective, practical method of teaching basic life support to large numbers of the
population.

Conict of interest
There are no conicts of interest.

Results of the ABC for life programme

Appendix A

173

174

P. Toner et al.

Results of the ABC for life programme

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