# Enhancing Equity in Schoolchildren’s Basic Life Support Education in Brazil Through Serious Games: Cohort Study

## TL;DR

A game-based CPR training program improved skills in Brazilian schoolchildren, reducing disparities between public and private school students.

## Contribution

Demonstrates that serious games can equitably enhance CPR skills across socioeconomic groups in low-resource settings.

## Key findings

- Older students (11-17 years) performed better in CPR quality than younger students (7-10 years).
- Gamified training improved CPR knowledge and skills across all participants, regardless of age or school type.
- Age, height, and grip strength were stronger predictors of CPR quality than socioeconomic factors.

## Abstract

Out-of-hospital cardiac arrests (OHCAs) predominantly occur in residential settings, often witnessed by children who could act as first responders. The World Health Organization (WHO) supports the Kids Save Lives (KSL) initiative, recommending basic life support (BLS) training for children aged ≥11 years. However, disparities in BLS education persist globally, particularly in low-resource regions where socioeconomic barriers, such as school type, malnutrition, and limited infrastructure, hinder implementation. Younger children (aged <11 years) face additional challenges due to physical limitations (eg, height, weight, and grip strength), which may compromise their ability to achieve adequate chest compression depth. While gamified learning has shown promise in improving BLS engagement and skill acquisition, its efficacy across diverse socioeconomic groups remains understudied.

This study aimed to compare cardiopulmonary resuscitation (CPR) performance (compression depth, rate, and recoil) between public and private school students following a game-based BLS intervention and evaluate the feasibility of a serious game (Kids Save Hearts) in improving BLS knowledge and irrespective of socioeconomic background.

We conducted an observational cohort study with 336 students aged 7‐17 years from 10 public and 10 private schools in Brazil (April to November 2022). Participants received 40 minutes of video-based CPR training (American Heart Association CPR in Schools) followed by 10 minutes of gamified training using the Children Save Hearts serious game (SG). CPR quality was assessed via quality of cardiopulmonary resuscitation (QCPR) scores (Laerdal QCPR manikin), measuring compression depth (mm), compression rate (per minute), and chest recoil. Anthropometric data (height, weight, and grip strength) and socioeconomic indicators (school type) were collected. Nonparametric tests (Mann-Whitney U and chi-square tests) and multivariate regression (SPSS v27.0; IBM Corp) were used to analyze associations between demographics, physical characteristics, and CPR performance.

Older students (11‐17 years) outperformed younger peers (7‐10 years) in median compression depth (48 mm vs 37 mm; P<.001) and overall QCPR scores (84 vs 42, P<.001). Private school students had higher grip strength (24.92 vs 21.48 g/cm²; P=.001), but school type did not significantly affect CPR quality. Postintervention SG scores improved universally (P<.001), with no age or socioeconomic disparities. Multivariate analysis identified age (P<.001), height (P<.001), and grip strength (P<.001) as independent predictors of high QCPR scores (≥70).

Age and physical development were stronger determinants of CPR quality than socioeconomic factors. The game-based intervention effectively improved BLS knowledge and skills across all participants, demonstrating its potential as an equitable training tool. These findings support the scalability of gamified BLS programs in resource-limited settings.