We conducted a prespecified posttraining survey to compare the effectiveness of incorporating a game-based mobile app into traditional training methods on CPR and AED theoretical knowledge, practical skills, willingness, and dissemination awareness of CPR and AED among university students. The participants received unified theoretical and operational training. Participants in the experimental group used a game-based mobile app for simulation exercises, whereas those in the control group received no additional intervention. In this study, we strictly followed the Consolidated Standards of Reporting Trial (CONSORT)-EHEALTH (V 1.6.1) guidelines for reporting mobile health intervention trials, as detailed in Checklist 1.

Using a convenience sampling method, 2 universities in the researcher’s city with comparable curricula were selected as research sites. Based on a natural grouping design, School A—which had similar curriculum systems, student compositions, and teaching resources—was assigned as the control group, while School B was designated as the experimental group. The inclusion criteria were as follows: adults aged 18 years or older, ownership of a smartphone (iOS or Android), and no prior participation in any CPR and AED training course. The exclusion criteria included physical limitations that would prevent the performance of CPR and AED techniques (including back or joint conditions).

This study was approved by the Medical Ethics Committee of the Affiliated Hospital of Qingdao University (QYFYWZLL29327). All participants took part voluntarily and provided written informed consent. Participants were informed of their right to withdraw at any time. To ensure privacy, all data were anonymized such that no individuals could be identified in any published results. In addition, no financial compensation was provided to participants.

The gamified app was designed based on the CPR and AED procedure guidelines provided by the Red Cross Society of China Training Center. Game scenarios were developed accordingly by the research team. Software engineers used the Cocos2D game engine and the C++ programming language for development, which helped reduce costs while maintaining professional quality and achieving high visual realism in operational scenes. The app is compatible with multiple operating systems, including Windows, Android, and macOS, and can be installed on devices such as laptops, tablets, and smartphones via a downloadable installation package. This enables users to operate the app anywhere, even without an internet connection.

The CPR and AED gamified app is divided into 2 portals: a student portal and an administrator portal. The student portal comprises 4 modules: Personal Information, Operational Practice Guidance, Game Module, and System Settings. The administrator portal includes 2 modules: Information Review and Data Statistics. By integrating CPR and AED operational content with game elements, the app is designed to enhance student engagement and learning interest.

Students activated the game by registering with their mobile phone numbers. During gameplay, users interact directly with on-screen elements—such as the shoulder, neck, center of the chest, AED storage compartment button, and AED electrode pad switch—by clicking on the relevant parts and following prompts to complete each step. When moving objects, such as a battery or an electrode plug, users can either click the object and then the target location or drag the object directly to the desired position. Students were required to correctly perform the CPR and AED procedure within a specified time limit. The practice scenario consisted of 6 sequential stages that had to be completed in the correct order. Screenshots illustrating the practice process in the CPR and AED gamification app are provided in Multimedia Appendix 1 (screenshots of the CPR and AED gamification app).

This study was conducted between March 21 and September 21, 2024. The training sessions were delivered by instructors certified by the Red Cross Society of China. To ensure standardization, all instructors first underwent a researcher-led briefing to ensure a comprehensive understanding of the CPR and AED program and its key learning objectives. On March 21, 2024, a 30-minute theoretical training session on CPR and AED was conducted, followed by a theoretical test. Subsequently, a 30-minute practical demonstration was performed by the researchers in accordance with the standard procedure. Each instructor was assigned to train 10 students, allowing 1 hour for independent practice and question-and-answer interaction. Finally, a training supervisor carried out the skill assessment based on unified evaluation criteria.

Subsequently, the researchers provided the installation package to participants in the experimental group and ensured that each student successfully completed the download and installation process. They also explained the app’s usage procedures and module functions to ensure that all students were familiar with its features. Students were permitted to use the game program freely at any time over the following 6 months, without needing to perform any additional operations. Each student was required to spend a cumulative duration of at least 30 minutes per week using the app and to complete at least 1 in-game level during that period. If a student failed to meet the level-completion requirement, the instructor was responsible for identifying the reasons and providing relevant guidance—addressing difficulties and questions raised during gameplay—until the student mastered the corresponding knowledge point and successfully passed the level. Instructors could access students’ learning data by searching for their names directly through the management portal.

No additional intervention was provided to the control group during the study period. However, these participants were offered access to the game-based mobile app after they completed the postintervention survey.

Prior to the commencement of the study, all data collectors and CPR and AED skill assessors received standardized training from the investigators. An electronic questionnaire was administered immediately after the theoretical training session to evaluate participants’ knowledge acquisition. Following practical skill training, participants were invited in batches to a unified testing center for CPR and AED skills assessment. Assessors were explicitly instructed that they would evaluate participants from any study group and were required not to inquire about or speculate on group assignments throughout the process. In line with the study protocol and consistent with the structure of our team’s first-aid courses at the university, both theoretical and practical tests were repeated 7 days later. Six months after completing the CPR and AED training, all participants were asked to complete a follow-up electronic questionnaire. This survey aimed to compare the 2 training methods in terms of long-term retention of theoretical knowledge, willingness to perform CPR, and dissemination of CPR-AED awareness.

The study used several questionnaires. First, a general information questionnaire was used to collect demographic data, including age, sex, and major. Second, the CPR and AED Theoretical Knowledge Questionnaire, developed by the Red Cross Society of China, was used. This instrument comprises 10 items covering key aspects of CPR and AED application, with total scores ranging from 0 to 100. The next section assessed participants’ attitudes and willingness to perform CPR and AED in cardiac arrest scenarios. The Willingness to Perform CPR and AED Questionnaire was developed by the research team based on a review of relevant literature [18,19], and the final version contained 6 items. Additionally, participants completed a modified version of the Dissemination of CPR Awareness Questionnaire, originally developed by Nas et al [20]. This modified instrument included 4 items specifically designed to evaluate the dissemination of CPR and AED awareness and was used to assess participants’ knowledge sharing in this domain.

The sample size calculation was based on a previous study [21], which reported significant differences in CPR compression depth and frequency compliance rates between a VR training group and a traditional training group (51% vs 75%; 50% vs 63%). Using these proportions (p_₁=0.50, p_₂=0.63), a 2-sided α of .05, and a statistical power (1 – β) of 80% (β=.20), the calculated sample size was 227 participants per group. To account for a potential 5% invalid response or attrition rate, the minimum required sample size was adjusted to 239 per group. Accordingly, this study enrolled 241 participants in the control group and 240 in the experimental group.

The formula used to calculate the sample size is as follows:

All statistical analyses were performed using SPSS version 27.0 (IBM Corp). Descriptive statistics were presented as means with SDs or as numbers and percentages, as appropriate. The normality of the data distribution was assessed using the one-sample Kolmogorov-Smirnov test. Since the skill scores deviated significantly from a normal distribution (df=481, P<.001), nonparametric tests were used for subsequent comparisons. The Mann-Whitney U test was used to compare outcomes between the 2 independent groups, whereas the Wilcoxon signed-rank test was applied for within-group comparisons across different time points. Categorical variables, expressed as numbers and percentages, were compared using the chi-square test or Fisher exact test, depending on the expected frequencies. All P values were 2-sided, and statistical significance was set at P<.05.

A total of 503 participants were enrolled in this study (n=252 in the experimental group and n=251 in the control group). After the 6-month intervention, which included 2 follow-up assessments, 4.8% (12/252) of participants in the experimental group and 4% (10/251) of participants in the control group were lost to follow-up or withdrew. Consequently, the final analysis included 240 and 241 participants in the experimental and control groups, respectively (Figure 1).

Table 1 presents the baseline characteristics of the participants. A total of 481 university students were included in this study, comprising 253 men and 228 women, with a median age of 20 (IQR 19-20) years. Regarding academic major, the proportion of medical students was comparable between the control group (38/241, 15.8%) and the experimental group (32/240, 13.3%). No statistically significant differences were observed in any baseline characteristics between the 2 groups (all P>.05).

At baseline, no significant differences were found in the theoretical and practical skills tests for CPR and AED between the control and experimental groups (P=.50 and P=.63, respectively; Tables 2 and 3). After 7 days, the experimental group achieved significantly higher scores than the control group in both theoretical knowledge and practical skills (P=.02 and P<.001, respectively).

In the control group, the theoretical score significantly decreased from the immediate posttest to the 7-day follow-up (P<.001; Table 2). In contrast, the observed decline in operational skills was not statistically significant (P=.22; Table 3).

In the experimental group, theoretical scores exhibited a statistically significant change between the immediate posttest and the 7-day follow-up (Z=−6.9, P<.001). Although the median scores remained constant at 90, the distribution of the data changed. This indicates a substantial redistribution in knowledge retention that is not reflected by the median alone (Table 2). Furthermore, practical skills demonstrated a significant improvement at the 7-day follow-up compared with the initial assessment (P<.001; Table 3).

The responses to individual CPR and AED theoretical knowledge questions are detailed in Table 4. The experimental group achieved a significantly higher total theoretical knowledge score than the control group (9 vs 8 points; P<.001). Notably, the experimental group also demonstrated superior performance on several key items: a higher proportion of the experimental group correctly identified the initial step as assessing scene safety (204/240, 85% vs 184/241, 76.3%; P=.02), the correct chest compression rate (200/240, 83.3% vs 174/241, 72.2%; P=.003), the appropriate compression depth (186/240, 77.5% vs 166/241, 68.9%; P=.03), and the correct compression-to-ventilation ratio (189/240, 78.8% vs 169/241, 70.1%; P=.03). No significant differences were found for the remaining items (Table 4).

Participants’ self-reported willingness to perform CPR and use an AED is summarized in Table 5. Overall, 34.1% (164/481) of participants felt capable of performing both CPR and using an AED. Of these participants, 29.9% (144/481) attributed this capability directly to the training received in the study, and this proportion did not differ significantly between groups (P=.53). When asked about assisting a stranger, a strong majority of participants (341/481, 70.9%) expressed willingness, with no significant difference observed between the control group (168/241, 69.7%) and the experimental group (173/240, 72.1%) (P=.85).

The vast majority of participants (461/481, 95.8%) reported that they would perform CPR and use an AED on a relative or friend, and no significant difference was found between the control group (232/241, 96.3%) and the experimental group (229/240, 95.4%) (P=.90). Overall, 56.3% (271/481) of participants felt capable of performing these skills, and 51.8% (249/481) reported confidence in recalling and applying first-aid skills when needed; neither measure differed significantly between groups (P=.96 and P=.94, respectively). In contrast, 42% (202/481) of participants reported fear of performing CPR and using an AED, with comparable levels between the control group (99/241, 41.1%) and experimental group (103/240, 42.9%) (P=.68).

The willingness to disseminate first-aid knowledge was high among participants, with 92.1% (443/481) expressing this intention.

Overall, 66.3% (319/481) of participants indicated that they would tell their family or friends about the importance of CPR, and this proportion did not differ significantly between the control group (66.8%, 161/241) and the experimental group (65.8%, 158/240) (P=.85). Similarly, 61.3% (295/481) of participants had already communicated with relatives or friends about the importance of CPR and AED training, with comparable rates between the control group (147/241, 61%) and the experimental group (148/240, 61.7%) (P=.94).

In total, 7.5% (36/481) of participants reported that their family members or acquaintances took concrete action, such as searching for CPR and AED training information, applying for a course, or attending a course. Although the proportion was higher in the experimental group (20/240, 8.3%) than in the control group (16/241, 6.6%), this difference was not statistically significant (P=.77). Detailed responses regarding the dissemination of CPR and AED awareness are provided in Table 6.

Integration of the game-based mobile app into training led to greater short-term mastery of both theoretical knowledge and practical CPR and AED skills compared with traditional methods. These findings are consistent with our previous research on other skill training [22] and are supported by preliminary studies indicating that gamification enhances learning outcomes in CPR training [23,24]. The app integrates game design elements into animated procedural simulations, which likely helps maintain learner engagement. Furthermore, its accessibility on mobile phones and computers allows for flexible, repeated practice in various settings. While these features position gamified mobile learning as a flexible, practical, and scalable tool—particularly when integrated with high-fidelity simulation—further rigorously designed studies are needed to confirm its long-term effectiveness and potential for optimizing CPR and AED training.

The follow-up assessment prioritized the evaluation of CPR and AED knowledge retention over practical skills, taking into account some participants’ upcoming internships or graduation. Results from the 6-month follow-up indicated a high level of knowledge retention, which is consistent with the findings reported by Nas et al [20]. In this study, the experimental group achieved marginally higher scores across the 10 CPR and AED knowledge items, and this difference was statistically significant. This outcome may be attributed to the game-based app’s emphasis on key procedural elements through a clear and visually engaging interface, which likely facilitates comprehension and long-term memory encoding. These observations suggest that a gamified mobile app could play a valuable role in supporting the sustained acquisition of CPR and AED knowledge. It is widely recognized that CPR and AED practical skills are prone to decay over time—a concern highlighted in the European Resuscitation Council Guidelines 2021 [25], which emphasize the need for regular retraining to sustain competency. These guidelines recommend distributing resuscitation training over time and maintaining competencies through frequent retraining. In this context, game-based mobile apps, given their accessibility and self-paced format, could effectively complement traditional training approaches, potentially extending reach and supporting ongoing skill maintenance.

Willingness to perform CPR and use an AED was generally high in both study groups. Compared with the control group, a greater proportion of participants in the experimental group expressed willingness to initiate CPR and AED procedures, and a slightly higher percentage reported feeling capable of assisting a person with cardiac arrest. This may be attributed to the game-based mobile app, which enabled repeated, low-stakes practice in diverse settings, thereby enhancing learners’ familiarity and self-efficacy. The self-paced learning feature likely reduced anxiety and fostered incremental confidence—advantages not typically offered by single-session training. Furthermore, the gamified environment may have contributed to a more engaging learning experience, potentially reducing the perceived dread and complexity associated with emergency scenarios [26]. Additionally, the app’s design, which breaks down the rescue process into clear, sequential steps with immediate feedback, may have helped users develop a structured mental model for responding in an actual cardiac arrest situation. Such clarity could alleviate the fear of making errors, a commonly reported barrier among lay responders [27]. However, the specific mechanisms underlying these effects require confirmation through studies specifically designed to establish causality. Notably, over 42% of participants across the study reported fear of performing CPR and using an AED, primarily due to concerns about causing secondary harm and facing legal consequences. These are widely documented barriers among laypersons, as also reflected in the study by Daud et al [15]. Together, these findings underscore that improving bystander willingness to act remains a critical challenge for future training initiatives.

Bystander-initiated CPR and rapid public access defibrillation are known to significantly improve survival outcomes after OHCA, with their combination exhibiting a synergistic effect [28]. A primary goal of resuscitation education for the public is, therefore, to raise awareness, train as many laypersons as possible, and develop innovative strategies to save more lives [29]. As is well known, the most common location for OHCA is the home or residence [30]; therefore, training that influences household members is of particular importance. In the present study, over 60% of the participants reported sharing information on the importance of CPR and AED with their family members or friends, indicating a potential diffusion of training awareness beyond the immediate learners. Some of these family members or friends took further active steps, such as searching for related materials, watching demonstration videos, or enrolling in formal courses, in response to participants’ encouragement.

This gamified mobile app was developed based on standardized CPR and AED training scenarios. Unlike traditional approaches such as on-site training or video-based instruction, it offers more flexible and accessible learning opportunities. The app incorporates game-like elements to promote interactive and intuitive engagement, as well as active participation among learners and their peers [31]. It also enables repeated, self-directed practice in diverse environments, which may strengthen familiarity with operational procedures. Furthermore, by breaking down the rescue process into sequential steps supported by real-time feedback, the app helps users establish a clear and actionable mental model for responding to an actual cardiac arrest. We propose that integrating this gamified CPR and AED training tool with conventional methods could serve as an effective complementary strategy for broadening the dissemination of CPR and AED knowledge and skills.

This study has several limitations. First, the use of a nonrandomized controlled trial design represents a key methodological constraint. The lack of random assignment to the experimental or control group may have introduced selection bias, thereby limiting the strength of causal inferences that can be drawn. Future research should employ randomized controlled trials to validate these findings. Second, although high theoretical knowledge retention was observed, the study did not assess the retention of practical skills. Thus, it remains unclear how well retained knowledge translates into actual CPR and AED performance in real-world settings. Subsequent studies should incorporate longitudinal evaluations of both knowledge and hands-on competencies in simulated or real cardiac arrest scenarios. Third, the absence of a preintervention survey prevented comparisons between baseline and postintervention outcomes, which similarly applies to measures such as willingness to perform CPR and dissemination of awareness. Finally, the generalizability of the findings may be limited by the study population, which consisted predominantly of young, highly educated participants with relatively high information technology literacy. The effectiveness of this game-based mobile app may vary among older adults, individuals with lower digital literacy, or those in different cultural settings. Future studies involving more diverse populations are needed to assess the broader applicability and effectiveness of this approach.

This study evaluated the integration of a game-based mobile app with traditional CPR and AED training. We assessed participants’ short-term acquisition of theoretical knowledge and practical skills, as well as long-term knowledge retention, willingness to act, and dissemination awareness after 6 months. The results indicate that supplementing traditional training with the game-based app may improve short-term mastery of both knowledge and practical skills and sustain knowledge retention over 6 months. Overall willingness to perform CPR and disseminate related knowledge was high, with no significant differences between groups. Despite the methodological limitations inherent in this nonrandomized study, the findings indicate that this accessible, interest-stimulating mobile learning tool may serve as a useful complement to existing CPR and AED training paradigms.