Application of the Modified Basic Life Support Training Model in Improving Community Residents' Rescue Willingness in Nantong City in China

Objective This study explores the application and effect of the modified basic life support training in improving the first-aid level and rescue willingness of community residents in China. Methods A total of 94 residents of a community in Nantong city were selected as the subjects by cluster sampling to receive the modified basic life support (BLS) training. The BLS knowledge, attitudes, and behaviors of all recruited subjects were evaluated by a questionnaire before and after training. A skill operation assessment was used to evaluate the effectiveness of the modified BLS training. Results There were statistically significant differences in the BLS rescue willingness, theory, and skill scores before and after the training (P < 0.01). A total of 93.62% of the residents considered the modified BLS training model easier to learn and acceptable than the traditional model, and 92.55% of them thought the training content and teaching arrangement were reasonable. Conclusion The modified BLS training model could improve the community residents' rescue willingness and skill mastery rates, enhance their first-aid skills and awareness, reduce the risk of disease transmission to a certain extent, and improve the success rate of prehospital first aid to ensure the safety of rescuers and patients.


Introduction
Te frst witness, namely the frst responder, refers to the frst person to witness an event or arrive at the scene [1]. Te "frst witness" can be any resident and is not specifcally a medical worker. Cardiac arrest (CA) is the leading cause of death in China's residents [2], and 70%-80% of CA events occur outside a hospital [3]. Basic life support (BLS) is the primary measure to rescue patients with CA, and their survival rate decreases by 7%-10% for every 1 min delay in the intervention [4]. Te survival rate of out-of-hospital patients with CA can be greatly improved if the frst witness can master BLS techniques. Te study by Liu and Jin [5] recruited 1212 Chinese participants and found that 55.2% of them had learned CPR, which was higher than the average CPR training rate in China in 2011 (25.6%). However, the cognition, implementation ability, and willingness of Chinese residents to initiate on-site frst aid remain at low levels [6,7]. Te existing investigations show that legal problems, lack of technology, and lack of confdence constitute the main factors afecting residents' rescue eforts [5,8,9]. Meanwhile, there is a lack of unifed and standardized BLS teaching curriculums and models in China, while the "practice while watching" (PWW) teaching method proposed by the American Heart Association (AHA) is a representative of standardized training [10]. Te modifed BLS training model is based on the 2020 AHA Guidelines for Cardiopulmonary Resuscitation and Cardiovascular Emergencies, which improves the traditional training model by addressing the above issues, making the BLS training more accessible and acceptable to the general population, without violating the principles of CPR. In this study, we aimed to explore the application of the modifed BLS training in improving the frst-aid level and rescue willingness of community residents in Nantong city in China.

Subjects.
Te residents of a community in Nantong city were selected from June 2021 to July 2021 as the study subjects by cluster sampling. Inclusion criteria were as follows: ① residents aged ≥18 years who volunteered to participate in the study; ② healthy residents who could perform cardiopulmonary resuscitation (CPR); ③ residents who could communicate and understand words; ④ nonmedical professionals. Exclusion criteria were as follows: ① those who could not learn due to serious audio-visual impairment; ② those who could not perform CPR due to obvious physical dysfunction or poor health conditions. Te whole-group random sampling method was used to enroll participants. Residents who met the criteria of enrollment were asked whether they were willing to participate in the study and the enrollment was on a voluntary basis. Te Ethics Committee of Nantong First People's Hospital approved this study, ethics no. 2020KT066.

Sample Size Calculation.
Te following formula was used to calculate sample size: n � [(μ α + μ β )α/δ]2 as previously described [8], where α � 0.05, β � 0.1. Te mean of the total questionnaire score of residents was 31.28 ± 8.45 points. Considering lost visits and midway withdrawal and that the sample size was expanded by 20%, the sample size was calculated as 80. Te total number of recruited subjects was 94 cases, which met the sample size requirement.

2.3.
Questionnaire. Te self-designed questionnaire for Basic Life Support Survey of Community Residents [11] prepared using the Delphi method was used in this study, with Cronbach's α coefcient of internal consistency of 0.719 and the retest reliability of 0.707. Te questionnaire mainly consisted of four parts, including the general circumstances of the subjects and three subquestionnaires about their BLS knowledge, attitudes, and behaviors. Te value assignment for "Yes or No" questions: 2 scores for "Yes" and 0 scores for "No;" questions on attitude: the Likert 3 score scale was used: 1 to 3 scores for "unwilling," "uncertain," and "very willing," respectively; multiple-choice questions: 2 scores for correct answers and 0 scores for wrong answers; multiple answer questions: 2 scores for correct answers, 1 score for incomplete answers, and 0 score for incorrect answers. Te questionnaire survey was conducted before and after the training, and the trained staf explained the survey before instruction without guiding language. Te questionnaire was flled in within 6-12 min to ensure its validity.

Basic Life Support Operation Evaluation Form.
Te adult BLS single and double operation evaluation forms of the AHA Training Center were used.

Satisfaction Survey.
Te self-designed questionnaire was used for the satisfaction survey. Te questionnaire contents included the community residents' views on whether the teaching content and course arrangement of the modifed BLS training model were reasonable, it was easy, it was in line with the residents' learning needs, and it was easier for residents to grasp the content. Te scores were given using the Likert 5 score scale, with the satisfaction (%) � ([number of "very satisfed" + "satisfed"]/total number of people) × 100%.
2.6. Training Outline. Te training outline was developed based on the AHA Guidelines for Cardiopulmonary Resuscitation and Cardiovascular First Aid in 2020 [4] (guidelines in 2020). Te investigation and research [8,[12][13][14][15] found that fear of legal problems, lack of knowledge, fear of disease transmission, and other factors constituted the main reasons for reluctance to assist in emergencies. Te modifed BLS training model improved the traditional training model in terms of the above factors. It focuses on the role of the frst witness in emergency situations, how to call for help, identifcation and judgment of patients in cardiac arrest, who is suitable for CPR, CPR operation standards, the requirements of high-quality CPR, the acquisition of AEDs, the basics of AEDs and operational points, the improvement of relevant laws, and so on; in the practical part, according to the requirements of the guidelines, the following content was added: the assessment of site safety, the way of judging patients in cardiac arrest, CPR compressions, AED operation specifcations, AED operation peculiarities, and simplifying the omission of mouth-to-mouth artifcial respiration. Te specifc training model was as follows: ① training duration: 40 minutes of theory training +2.5 hours of operation training. ② Teory training: the subjects were taught intensively with lectures, which focused on the role of the frst witness in emergencies, how to correctly dial the telephone for help, how to identify and judge patients with CA, and who can receive CPR, as well as its operating standards and high-quality requirements, the acquisition of an automatic external defbrillator (AED), its fundamental information and operation essentials, and the improvement of relevant laws. ③ Operation training: the teaching videos were recorded by qualifed AHA trainers, including on-site safety assessments, judgment methods of CA, chest compressions, AED operation specifcations, and specifcity, with mouth-to-mouth resuscitation omitted. Te "PPW" teaching method [11] was used to ensure the training outcome; there was one trainer and eight to ten students. Te students could train on a simulator with a feedback device while watching a video. Te trainer would provide the whole-course guidance and explanations to correct any problems immediately and ensure the accuracy and efectiveness of the procedure.

Statistical
Methods. Te Questionnaire Star was used for data statistics. SPSS 21.0 statistical software was used for data analysis after import. Te measurement data were expressed as mean ± standard deviation (X ± s), and the enumeration data were expressed as frequency and percentage, followed by descriptive statistics and paired t-tests for analysis.

Comparison of Basic Life Support
Knowledge of the Residents before and after the Training. Te scores of BLS knowledge, beliefs, and behaviors of 94 community residents after training were signifcantly higher than before training, and the average score was 11.09 ± 4.11 and 23.42 ± 6.61, respectively, before and after the training, with diferences in each item statistically signifcant (P < 0.05), as shown in Table 2.

Comparison of the Residents' Basic Life Support Rescue
Willingness before and after the Training. Te diference in the scores of the residents' BLS rescue willingness before and after the training was statistically signifcant (P < 0.05), with the scores of each item shown in Table 3.

Comparison of the Residents' Basic Life Support
Behavior before and after the Training. Te residents' average BLS behavior scores were 9.84 ± 1.756 and 13.22 ± 2.20, respectively, before and after the training. Tere were statistically signifcant diferences in whether the community residents could correctly judge patient consciousness, skillfully perform BLS operations, and timely obtain an AED before and after the training (P < 0.05), with the scores of each item shown in Table 4.

Basic Life Support Process Assessment of the Residents.
A total of 53 community residents (56.38%) passed the operation assessment the frst time, and 41 residents (43.62%) passed it after guidance.

Te Residents' Satisfaction with the Training Model.
A total of 92.55% of the residents considered the modifed BLS training model reasonable in teaching course content arrangement, 93.62% believed this model was easier for ordinary people to learn and master BLS techniques, and 91.50% felt the course arrangement met their learning needs; as shown in Table 5.

Efects of the Modifed Basic Life Support Training Model on the Community Residents' Knowledge and Behavior.
Te teaching application of the modifed BLS training model was studied by the community residents in Nantong city. Te study results showed that the residents' BLS knowledge scores after training were signifcantly higher than before training; the diference was statistically signifcant. Terefore, it could be concluded that skill training could improve the community residents' level of BLS knowledge. Tis was consistent with the study results conducted by Sun et al. [16], which demonstrated that training could improve the publics' CPR cognition and skill mastery. According to a study on BLS  [18] that it is tough for the public to obtain an AED. Although more than 40% of the residents received CPR training to some extent, their skill mastery was not ideal, and most of them did not even know the correct procedure for CPR and could not take proper rescue measures for out-of-hospital patients with CA. According to the results of this study, the behavioral ability of the community residents was signifcantly improved after training, especially in terms of AED acquisition ability; the diferences were statistically signifcant before and after the training. Te higher the community residents' level of BLS knowledge contributed to a more positive attitude and stronger behavioral ability.

Te Modifed Basic Life Support Training Model can Improve Community Residents' Rescue Willingness.
When cardiovascular incidents occur, especially sudden death, lack of knowledge is an important factor infuencing the "frst witness" to provide rescue immediately [19]. Lack of knowledge makes residents fear legal liability after the rescue, which is a non-negligible situation in China [8].
Although it has been made clear that a rescuer should not bear legal responsibility for damage caused to a patient in the rescue process, relevant news reports are still common.
Tere is still a long way to go for law popularization and BLS knowledge publicity and citizens' self-help and call-for-help awareness are still insufcient.
Tere were signifcant diferences in the willingness of the public to provide rescue in emergencies before and after training, and the modifed training model can greatly improve their preparedness, which may be associated with the    During the practice, the trainers provided guidance and broke down the key points so that the public could perform the skills rather than learning the theory or watching videos only. In the opinion of 93.62% of the residents, the teaching content of the modifed BLS training model made it easier for ordinary people to master, indicating that it was easier to accept than the traditional training. According to the guidelines in 2020 [5], nonprofessionals should focus on chest compression rather than mouth-to-mouth resuscitation, as incorrect artifcial respiration may cause complications, such as hyperventilation, neck injury, and sufocation. Studies have shown [20] that there are no statistically signifcant diferences in the survival and success rates of frst aid between the patients receiving chest compression alone and those receiving chest compression + artifcial respiration. Tis training omitted the "mouth-to-mouth resuscitation" step and focused on teaching using an AED and chest compressions, making it acceptable for more residents. Tis was consistent with the views in the guidelines in 2020 that CPR with chest compression alone was easier for the public to learn than traditional CPR (chest compression + mouth-tomouth resuscitation). Cho and Kim [21] found that the skill accuracy of CPR training with chest compression alone was 28.5% higher than traditional training methods. Meanwhile, the omission of the "mouth-to-mouth resuscitation" step helps people pay more attention to the accuracy of the chest compressions, reduces the complications caused by improper ventilation, and dramatically reduces concerns about disease in the current challenging time of COVID-19, which increases people's willingness to help. Moreover, compared with the traditional BLS model, the modifed BLS model focuses more on operational practice in terms of time and devotes most of the training practice to practice and correction. One instructor can train 8-10 trainees to ensure training quality and efciency. In terms of instructor selection, instructors are all AHA registered ACLS instructors in the U.S. with rich teaching experience, who can design scenarios for training according to the needs of the scenario and highlight practicality. Due to the impact of the COVID-19 pandemic, a comparison with traditional models was not conducted in this study. In addition, foreign studies have shown that people's reserve memory of frst aid skills and knowledge will decline signifcantly within one week [22] and after six months for professionals [23], which reminds us of the need for retraining to strengthen knowledge and skills [24]. Moreover, there is evidence that retraining is benefcial to effectively preserve learning and skill memory [25], but there are no clear regulations on the interval of retraining at home and abroad. Tis study has not yet proposed a specifc scheme of BLS retraining for the public, which will be further studied and discussed in the future.

Conclusion
Te modifed BLS training model could improve the community residents' rescue willingness and skill mastery rates, enhance their frst-aid skills and awareness, reduce the risk of disease transmission to a certain extent, and improve the success rate of prehospital frst aid to ensure the safety of rescuers and patients.

Data Availability
Te data that support the fndings of this study are available from the corresponding author upon reasonable request.

Ethical Approval
Tis study was approved by the Ethics Committee of Nantong First People's Hospital (approval number: 2020KT066).

Conflicts of Interest
Te authors declare that they have no conficts of interest.