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Globally, 3.7 million people die of sudden cardiac death annually. Following the World Health Organization endorsement of the
This study aims to systematically evaluate the quality, usability, evidence-based content, and gamification features (GFs) of commercially available m-learning apps for teaching guideline-directed BLS knowledge and skills to school-aged children.
We searched the Google Play Store and Apple iOS App Store using multiple terms (eg,
Of the 1207 potentially relevant apps, only 6 (0.49%) met the inclusion criteria. Most apps were excluded because the content was not related to teaching schoolchildren BLS. The mean total scores for the user version of the Mobile Application Rating Scale and System Usability Scale score were 3.2/5 points (95% CI 3.0-3.4) and 47.1/100 points (95% CI 42.1-52.1), respectively. Half of the apps taught hands-only CPR, whereas the other half also included ventilation. All the apps indicated when to start chest compressions, and only 1 app taught BLS using an automated external defibrillator. Gamification was well integrated into the m-learning apps for teaching schoolchildren BLS, whereas the
Improving the quality and usability of BLS content in apps and combining them with GFs can offer educators novel m-learning tools to teach schoolchildren BLS skills.
Sudden cardiac arrest is a leading cause of mortality, responsible for 3.7 million deaths per year [
Following the World Health Organization endorsement of the
The ERC guidelines for resuscitation recommend that the use and development of technology and social media should be encouraged and the impact, assessed [
We conducted a systematic search of commercially available apps using a rigorous methodology that has been previously published [
Our search strategy was conducted in three rounds. First, the apps were searched using search strings (
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of app selection. BLS: basic life support.
The inclusion criteria for the selection of emergency health care professionals were as follows: above 18 years, CPR training certification by an established medical association, and more than 5 years of experience teaching emergency medicine. A total of 15 emergency health care professionals rated each app independently in a laboratory environment using two validated rating tools, the user version of the Mobile Application Rating Scale (uMARS) [
The study was conducted in a central European country (Slovenia). All emergency health care professionals signed informed consent to participate, and ethics approval was obtained from the two Health Care Centre in the north-eastern part of Slovenia.
uMARS provides a multidimensional measure of performance indicators, functionality, esthetics, and quality of information. Apps’ subjective quality was not assessed. All items were rated on a 5-point Likert scale ranging from 1 (inadequate) to 5 (excellent). The SUS includes 10 statements on a 5-point Likert scale with both positive and negative statements about usability. The total score for the SUS is 100 points, which is divided into six usability categories including worst imaginable (0-25 SUS score), poor (25.1-51.6 SUS score), ok (51.7-62.6 SUS score), good (62.7-72.5 SUS score), excellent (72.6-84.0 SUS score), and best imaginable (84.1-100 SUS score) [
In total, 3 investigators evaluated evidence-based BLS in each app using the ERC [
We modified gamification taxonomy [
We used Microsoft Office Professional 2016, R (version 3.6.0, R Foundation for Statistical Computing), SPSS Statistics for Windows (version 27.0, IBM Corp), and Inkscape 1.0 (Inkscape Developers, GNU General Public License) to analyze and visualize the results. The interrater reliability for uMARS and SUS was calculated using the intraclass correlation coefficient (ICC2, k; intraclass correlation coefficient, two-way random, average measures, and absolute agreement) [
We identified 1207 apps. The PRISMA flow diagram presents the process of selecting and scanning apps using the inclusion and exclusion criteria. After removing duplicates from multiple search strings from web-based mobile smartphone stores, 63.29% (764/1207) apps remained; 4.88% (59/1207) apps were relevant to BLS, m-learning, and gamification. After applying all the inclusion and exclusion criteria, 0.49% (6/1207) apps were included in the final evaluation (
All apps were classified into the
Description of the included apps.
Full App Name | Health care organization collaborator | Country, BLSa guideline organization | Description of BLS scenarios |
St John Ambulance Australia (Victoria) | Australia (St John Ambulance Australia) | One scenario in which the user performed BLS, first on a conscious and second on an unconscious animated cartoon figure | |
Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong | United States (American Heart Association) | No scenario. In the simulation environment, the user performed BLS on an animated human figure | |
Life Saving Victoria Limited | Australia (St John Ambulance Australia) | Three scenarios in which the user performed BLS on a drowned adult, a drowned child, and an unconscious animated cartoon figure | |
The Italian Resuscitation Council | Italy (The Italian Resuscitation Council) | Two scenarios in which the user performed BLS on an animated animal that was choking and one that experienced cardiac arrest | |
The University of Pittsburgh, Department of Emergency Medicine | United States (American Heart Association) | Two scenarios in which the user performed BLS on an unconscious and a conscious animated human figure | |
Emergency Response Centre Agency Finland, Finnish Recovery Council, Finnish Fire Officers’ Association’s | Finland (Finnish Recovery Council) | One scenario in which the user performed BLS on an animated human figure that experienced cardiac arrest |
aBLS: basic life support.
Most apps targeted children aged above 4 years of age, and 1 app—
A total of 15 emergency health care professionals participated (3 females and 12 males) in evaluating apps using uMARS and SUS. In total, 40% (6/15) of the participants were nurses, 27% (4/15) were nurses with a master’s degree, and 33% (5/15) were physicians. Overall, the mean age of emergency health care professionals was 36 years. All emergency health care professionals had an Advanced Life Support (ALS) certificate provided by the ERC, and their mean professional experience was 13 years. All emergency health care professionals own and were proficient daily users of mobile smartphones.
The mean total uMARS rating of apps was 3.2/5 (95% CI 3.0-3.4), and the details across the four domains are shown in
User version of the Mobile Application Rating Scale results and time spent on each app.
Full app name | uMARSa section | Timeb | |||||
|
Engagement | Functionality | Aesthetics | Information | Overall app quality |
|
|
3.7 | 4.0 | 4.0 | 3.9 | 3.9 | 12 | ||
3.1 | 3.7 | 3.2 | 3.7 | 3.4 | 7 | ||
3.5 | 3.0 | 3.7 | 3.5 | 3.4 | 24 | ||
2.9 | 3.5 | 4.1 | 3.7 | 3.5 | 5 | ||
2.8 | 3.6 | 3.2 | 3.5 | 3.3 | 5 | ||
3.4 | 3.4 | 3.6 | 3.2 | 3.4 | 4 |
auMARS: user version of the Mobile Application Rating Scale.
bMean time for testing apps (in minutes).
Mean scores and intraclass correlation coefficients of the user version of the Mobile Application Rating Scale and time spent on each app.
Variable | Score, mean (95% CI) | ICC2, ka (95% CI) | |||
|
|||||
|
Engagement | 3.2 (3.0-3.4) | 0.9 (0.8-0.9) | ||
|
Functionality | 3.5 (3.4-3.7) | 0.7 (0.5-0.8) | ||
|
Aesthetics | 3.6 (3.4-3.8) | 0.8 (0.6-0.9) | ||
|
Information | 3.6 (3.4-3.8) | 0.8 (0.6-0.9) | ||
|
Overall app quality | 3.2 (3.0-3.4) | 0.9 (0.8-0.9) | ||
Time for testing apps (min) | 9.2 (7.7-10.7) | N/Ac |
aICC2,k: intraclass correlation coefficient; two-way random, average measures, absolute agreement.
buMARS: user version of the Mobile Application Rating Scale.
cN/A: not applicable.
System Usability Scale results in the form of a box plot for each review app. SUS: System Usability Scale.
The overall evaluation of evidence-based BLS content in the apps was
Basic life support groups and percentages of basic life support contents in the apps. AED: automated external defibrillator; BLS: basic life support; CPR: cardiopulmonary resuscitation.
The most common GFs in apps were in
Gamification groups and features in all the apps. GF: gamification feature.
We conducted a systematic evaluation of the quality, usability, evidence-based content, and GFs of commercially available m-learning apps for teaching guideline-directed BLS knowledge and skills to school-aged children. Overall, the quality of the apps was
Many of the apps analyzed in this review were not high-quality apps according to the uMARS tool. Overall, the lowest mean uMARS score was represented in the engagement section, evaluating entertainment, interest, customization, interactivity, and target group. Future apps could learn from this review by ensuring that user engagement is prioritized during the development phase. From a customization perspective, some personal app options (eg, selecting gender or adding names of a player) or BLS options such as changing BLS victims or scenarios, including or excluding ventilation as a part of CPR, and varying chest compression frequency should be added. Nevertheless, the information section represented the highest uMARS score, and app developers should consider adding more relevant evidence-based BLS contents to BLS m-learning apps.
Relevant to functionality and esthetics, schoolchildren prefer visually attractive apps [
This review represented the poor-to-average quality of BLS content regarding international BLS guidelines [
We classified BLS training for schoolchildren using a modified version of the
In terms of safety, only half of the apps were designed to check whether the area was safe before approaching the victim. All BLS guidelines reinforce the importance of ensuring safety for first responders, victims, and bystanders [
Consciousness, in most apps, was assessed by checking the victim’s responsiveness to the question, “Are you all right?” and gently shaking the victim. For example, in the
As recommended in the CPR guidelines [
Most apps correctly demonstrated how to make an emergency service call using the speakerphone function. For example, in the
The most common BLS content included in apps was chest compressions. According to the modified CPR guidelines [
An alternative approach to indicating the point for compression using a circle is to interact with the phone by holding the smartphone in the palm, facing up, and moving it up and down with the chest compressions. This method facilitates immediate visual feedback on how chest compressions should be performed. A limitation of the apps was that the compression site was inconsistently labeled, leading to inaccurate hand and arm positions. According to a study conducted in 2019, consistency with hand and arm positions is critical for chest compression accuracy [
Our results indicate that half of the apps do not include steps for ventilation when teaching CPR. Those that do include ventilation provide accurate BLS contents about how to perform mouth-to-mouth ventilation. However, ventilation volume and verification of chest rising are poorly integrated into the ventilation part of CPR. A study from 2019 indicated that teaching schoolchildren ventilation requires more teaching time, and it is harder to establish good quality BLS results [
Overall, the use of AEDs was poorly represented. Only the
Recently, gamified m-learning has become increasingly popular in various medical and educational contexts, including BLS training [
Schoolchildren today have high smartphone literacy, but less is known about educators. To use m-learning to teach BLS to schoolchildren, educators must feel confident about the platform. Some resuscitation councils, such as the Italian Resuscitation Council [
Using gamified learning features, educators can expect changes in psychomotor, cognitive, and affective learning outcomes [
We deliberately selected emergency health care professionals and not schoolteachers to review the apps because we were focused on adherence to evidence-based guidelines for educational purposes. There were also a small number of final apps, probably as a result of our prespecified criteria, including focusing on a target population below 13 years of age and free apps. In addition, a few apps were excluded because of limitations in language design (eg, Held: Reanimatie Game, in Dutch) [
The results of this study provide opportunities for developing an app for teaching BLS to schoolchildren. The
Our study represents an opportunity to include m-learning apps for teaching BLS to schoolchildren. Using an adapted
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.
Basic life support groups and contents.
Gamification groups and features.
Description of the included apps.
User version of the Mobile Application Rating Scale scores and sections.
User version of the Mobile Application Rating Scale and time spent on each app results.
automated external defibrillator
American Heart Association
Advanced Life Support
basic life support
cardiopulmonary resuscitation
European Resuscitation Council
gamification feature
intraclass correlation coefficient
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
system usability scale
user version of the Mobile Application Rating Scale
This study was partially supported by the
This study was conducted with collaboration among all authors. NF developed the study design and supervised the study. NF, LG, and RMC drafted the manuscript. NF, LG, ND, and GS collected and analyzed the data. NF, MS, and PS interpreted the results from a BLS point of view. RMC, DE, and BC conducted a comprehensive review of the content. All authors read, revised, and approved the final manuscript.
None declared.