Implementation of school-based CPR training - A systematic review and mixed-methods meta-analysis

Aim: Despite initiatives like "Kids Save Lives", CPR trainings are often poorly implemented, and bystander CPR rates remain low. This systematic review and mixed-methods meta-analysis of qualitative and quantitative studies aims to identify enablers and barriers to the implementation of school-based CPR training. Methods: A systematic search was conducted across seven databases. Qualitative data were analyzed using thematic synthesis, and findings were evaluated with GRADE-CERQual. Quantitative data were synthesized through qualitative findings, providing deeper context using a convergent qualitative meta-integration approach. Results: A total of 18 reports (7 qualitative and 11 quantitative) on school-based CPR training were included from an initial pool of 7914 records. Key enablers of successful school-based CPR training implementation were related either to program characteristics or to environmental factors, with both being equally important. Generally, programs are better implemented if they include high-quality resources, incur low costs in terms of funds, time and staffing, show adaptability to the setting in which they are implemented, and provide standardized training for teachers or implementers. Regarding environment factors, implementation is facilitated by broad support from school stakeholders (leadership, teachers, and parents) and is more successful where, supported by mandatory legislation and government endorsement, health is framed as a core business of schools. Conclusion: The successful implementation of school-based CPR training depends on both program characteristics and environmental factors, operating together in a "seed and soil" manner. Addressing both aspects is essential for effective program planning. Future research should more broadly explore health outcomes beyond CPR-related measures and investigate how CPR training can be integrated into wider health-promoting school initiatives.