1. Introduction

Evaluation of factors that could influence the effective provision of bystander cardiopulmonary resuscitation (CPR) is crucial in realising the best possible outcomes in out-of-hospital cardiac arrest (OHCA) victims. The global public health challenge of OHCA has been on the increase [1-5].

Previous studies have provided conflicting reports on gender associations with cardiopulmonary resuscitation knowledge [6-9]. Cardiopulmonary resuscitation (CPR) is an emergency procedure performed as an attempt to restore spontaneous circulation by performing chest compressions with or without ventilations [10]. Studies have also shown that poor CPR knowledge has contributed to the fear and reluctance to attempt bystander CPR for victims of OHCA [11-14]. Adequate information on influence of gender on CPR could help to adjust or improve future education in cardiopulmonary resuscitation. Amacher et al [15] reported that female gender was associated with a lower number of secure leadership statements. They concluded that future education of rescuers should take gender differences into account [15]. Wigginton et al [16] stated that they believed gender-and sex-related differences in resuscitation are important, and that research designed to both better understand and better treat these differences may significantly improve outcomes in the nearfuture.

Although there are few reports from Nigeria on theoretical knowledge of cardiopulmonary resuscitation [17-21], there is need to explore further any significant association of gender of the potential bystander CPR providers with the theoretical CPR knowledge. In addition, the previous related studies were based only on conventional CPR training of participants.

Therefore, this study aimed at assessing the possible impact of participants’ gender on the post-training theoretical knowledge of bystander CPR involving both the conventional CPR group and the hands-only CPR group. We hypothesized that: (1) the gender of the participants would not have any significant association with the post-training theoretical CPR knowledge in the conventional CPR group; (2) the gender of the participants would not have any significant association with the post-training theoretical CPR knowledge in the hands-only CPR group; and (3) there would be no statistically significant gender differences in the post-training CPR knowledge acquired by the participants when the separate groups are compared.

2. Materials and Methods

2.1. Research Design

This study was carried out using a quasi-experimental cohorts design – one cohort was exposed to the conventional CPR training while the other cohort was taught hands-only CPR technique. However, both cohorts were taught together during the theoretical teaching before the different hands-on sessions.

2.2. Population of the Study

The two groups (cohorts) were part of the larger 200-Level students of the Department of Human Kinetics and Health Education in the Faculty of Education of the University of Port Harcourt. The students were admitted into the Department in 2016. Although not all the thirty six (36) States in Nigeria are represented in the sample, but due to the Admission Policy in all the Federal Universities in Nigeria which ensures that candidates from all the six (6) Geo-political Regions in the country are fairly admitted into every programme, the participants gave a very fair representation of the different States in Nigeria.

2.3. Stage 1 (Pre-training Phase)

Before CPR teaching and trainings, one hundred and forty (140) copies of a self-administered questionnaire on their knowledge of cardiopulmonary resuscitation (CPR) were distributed to assess the pre-training CPR theoretical knowledge of the participants - seventy (70) in the hands-only cohort and another seventy (70) in the conventional CPR group. Nine questions on bystander CPR were captured in the questionnaire (Appendix).

2.4. Stage 2 (Immediate Post-training Phase)

Immediately after the teaching and trainings on bystander CPR, another one hundred and forty (140) copies of the same questionnaire were given to the same participants to answer the same questions on CPR which they answered before the teaching and training sessions. All the participants in the two groups responded to the questions again.

2.5. Determination of Good and Poor CPR Theoretical Knowledge

For each of the nine (9) questions on CPR knowledge, a score of 50% was considered good while any score less than that was considered as poor CPR theoretical knowledge. (See the 9 questions on CPR knowledge in the attached Appendix).

The following null hypotheses were generated and tested:

Ho1: That the gender of the participants would not have any significant association with the post-training theoretical CPR knowledge in the conventional CPR group

Ho2: That the gender of the participants would not have any significant association with the post-training theoretical CPR knowledge in the hands-only CPR group

Ho3: That there would be no statistically significant gender differences in the post-training theoretical knowledge of the two cohorts compared.

2.6. Data Analysis

The Statistical Package for Social Sciences (SPSS Version 20) was used to analyse the data. In addition to descriptive statistics, the data was analyzed using the analysing of variance (ANOVA) at P < 0.05 level of significance.

3. Results

Both Hands-Only and Conventional CPR groups had 70 participants each with equal number of males and females: 54(77.1%) females and 16(22.9%) males in each group and mean ages of 21.26 + 2.92 (SD) and 21.17 + 2.59 (SD) for hands-only and conventional groups, respectively.

Table 1 below provides the post-training CPR knowledge of the two cohorts according to gender showing similar patterns.

Table 1. Post-training CPR knowledge of the participants according to gender for the two training techniques

The analysis of variance (ANOVA) of the post-training CPR knowledge of the participants in the hands-only CPR group with their gender is shown in Table 2 with the male gender giving a statistically significant better CPR knowledge than the female (P = 0.041) in question 3. This means the rejection of the first null hypothesis with respect to question 3 but accepted for the rest. Table 3 below shows the analysis of variance (ANOVA) of the post-training knowledge of the participants in the conventional CPR group with their gender. Statistically significant gender differences were seen with respect to questions 5 and 7 with P = 0.009 and P = 0.027, respectively. This means the rejection of the second nullhypothesis for questions 5 and 7 but accepted for the rest because the male gender had statistically significant better CPR knowledge than the female gender in question 5 while the female gender had statistically significant better CPR knowledge with respect to question 7.

Table 2. Analysis of Variance (ANOVA) of the post-training CPR knowledge of the participants in the hands-only CPR group with their gender

Table 3. Analysis of Variance (ANOVA) of the post-training knowledge of the participants in the conventional CPR group with their gender

Analysis of Variance (ANOVA) of the difference in post-training CPR knowledge in the hands-only CPR and the conventional CPR groups is shown in Table 4 below. No statistically significant difference was detected with respect to the genders when the two cohorts were compared (P > 0.05). The third null hypothesis is hereby accepted.

Table 4. Analysis of Variance (ANOVA) of the difference in post-training CPR knowledge in the hands-only CPR and the conventional CPR groups

4. Discussion

The present Nigerian study has generally shown that there was no consistent association of any gender with CPR knowledge, as well as no significant differences between the two cohorts. The current finding of this study is consistent with an earlier related Nigerian report [20].

This present finding of this Nigerian study is very much in line with the conflicting findings in the literature about gender and CPR knowledge as stated earlier [6-9]. The study by Alkandari et al [7] showed that gender significantly associated with CPR knowledge among dentists in Kuwait. Alsharari et al [8] did not find any statistical gender differences in the variables (questions) that were used to assess the CPR knowledge of their participants.

Alotaibi et al [9] reported higher CPR mean score by the female gender than their male counterparts in the study. Parnell et al [22] reported no general poor CPR knowledge among the studied students without any significant differences between the male and female participants. According to Amatya and Gorkhali [23], knowledge score did not correlate significantly with sex among the health personnel who generally had poor CPR knowledge.

Although they found comparable male and female CPR knowledge, Krammel et al [24] recommended that specially tailored programmes should be put in place to increase the awareness and willingness among both the female and elderly community for future educational intervention.

Their recommendation was occasioned by the general poor CPR knowledge with females and the elderly lacking the willingness to perform CPR among the Viennese population. In the study by Tsegaye et al [25], 83% of the male University undergraduate medical students had good CPR knowledge as against 10% of their female counterparts.

However, no significant association was found between sex and the CPR knowledge of the students but there was significant association between academic year, source of information of CPR and knowledge of CPR.

The Strengths and Limitations of this study

The study samples for the two cohorts were drawn from a fairly representative population of students admitted to a Federal Government University where candidates are uniformly selected from different states of the country. However, the male and female proportions were not even in this study which we could not influence as the female/male ratio reflect the actual number of both genders in the entire class. In addition, the sample sizes for the two cohorts were not very large and as such the generalization of the results should be done with caution.

5. Conclusions

This study has revealed no consistent gender association with either of the genders for any of the CPR training techniques. However, statistically significant gender associations were found in three of the CPR knowledge questions only.

6. Recommendations

There is need to carry out more gender-specific cardiopulmonary resuscitation (CPR) studies with larger samples in Nigeria involving the body mass index (BMI) of the participants.

The Federal Government of Nigeria should without delay promote the introduction of CPR education in Nigerian schools (primary, secondary and higher institutions) so as to increase the number of bystander CPR providers in our communities.

Appendix

QUESTIONNAIRE ON CPR

Section A: Personal Data

Please tick as it applies to you

1. Gender :

2. Age in years:

---------------------------------------------------

3. Faculty: --------------------------------------------------------

Department: -------------------------------------------

Level: ---------

Matriculation No: ----------------------------------

Section B: Please honestly provide your answers to these questions on CPR

4. What is the first thing you should do if you come across a collapsed person

Call an ambulance

Try to get the person to respond to you

Check to see if the person is breathing normally

5. Why would you shake and shout at a collapsed person?

To open the airway

To restart the heart

To check for response.

6. The five steps in the Adult Chain of Survival include all of the following EXCEPT

Early CPR

To check for response

Advanced airway placement

7. What action would you use to open the person’s airway?

Tilt the head back and lift the chin

Tilt the head and push the chin down

Tilt the head down and turn the chin to the right

8. If a victim has dentures, what should you do?

Remove the denture

Leave them in position as long as they are not obstructing the airway

Use the of nose

9. What is the first link in the “chain of survival” for cardiac arrest victims?

Early recognition of a cardiac arrest

Cardiopulmonary Resuscitation

Citizen Please Respond

10. When giving rescue breaths, for how long do you breathe into the person’s mouth

1 second

5 seconds

10 seconds

11. Which of the following are signs of airway obstruction?

Poor air exchange

High-pitched noise while inhaling

Inability to speak

All of the above

12. How many chest compressions and rescue breaths would you give per cycle of CPR?

20 presses and one breathe

30 presses and two breaths

30 presses and three breaths

THANK YOU.