Article Text
PDF
Abstract
Background Cardiopulmonary resuscitation (CPR) manikins typically appear white, lean and male. However, internationally, this does not represent the overall population or those who are at greatest risk of cardiac arrest. Diverse demographic groups including people of colour, women and obese people are known to be less likely to receive bystander CPR, public access defibrillation and suffer less favourable outcomes. It is plausible that failure to represent women, racially diverse and non-lean manikins can contribute to poor clinical outcomes in these populations. The aim of this scoping review was to summarise the current evidence for adaptations of manikins used for layperson Basic Life Support (BLS) training.
Methods We searched MEDLINE, Embase, PsycINFO, CINAHL, ERIC, Web of Science, Infromit, Scopus and Cochrane Central Register of Controlled Trials to identify all empirical studies describing or evaluating CPR manikin diversity. Data on participant characteristics, manikin adaptations, study design, and key findings of included studies describing or evaluating CPR manikin diversity were extracted.
Results Initially, 2719 studies were identified, and 15 studies were finally included and were grouped into (1) studies analysing adaptions of ‘standard’ manikins used in training (n=11) and (2) studies evaluating CPR manikin diversity used for online learning and on social media (n=4). Six of the studies analysing different adaptations reported the influence of the manikins’ sex on comfort in performing CPR, quality of chest compression, automated external defibrillator use and removing clothes; four the effects of obese manikins; and one an ethnically diverse manikin. Seven of the studies used do-it-yourself adaptions. Racial and gender diversity of CPR manikins found in educational videos was limited, with only 5% of educational videos featuring non-white manikins and 1% featuring female manikins.
Conclusion Adaptations of manikins used for BLS CPR training for laypersons still do not represent the diversity of communities most people are living in, internationally. There are hints that using diverse racial manikins has the potential to improve engagement in CPR training. Reported barriers hindering the use of adapted manikins were high costs and availability of these manikins.
- Cardiopulmonary Resuscitation
- chain of survival
- Defibrillators
- education
- Healthcare Disparities
Data availability statement
Data are available upon reasonable request. Data will be made available upon reasonable request due to national and organisational law.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
WHAT IS ALREADY KNOWN ON THIS TOPIC
Manikins for layperson cardiopulmonary resuscitation (CPR) training are typically white, lean and male, while certain sociodemographic groups experience lower bystander rates, defibrillator use and survival rates after out-of-hospital cardiac arrest.
WHAT THIS STUDY ADDS
We identified 15 studies focusing on adaptations of manikins used for layperson Basic Life Support training, of which 11 analysed adaptions of ‘standard’ manikins used in training, and 4 evaluated manikin diversity used for online learning and on social media.
Only one study evaluated the view of ethnically diverse people on racially diverse manikins and how these adaptions should be conducted.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
By discussing the limitations of ‘standard’ manikins used for training and their possible influence on sociodemographic disparities in CPR outcomes, educators all over the world should be part of the solution.
To improve cardiac arrest outcomes among these groups, organisations involved in CPR education should ensure diversity of manikins, and manufacturers should offer low-cost diverse manikins.
Introduction
Cardiopulmonary resuscitation (CPR) manikins typically appear white, lean and male, but internationally, this of course does not represent the overall population or those who are at greatest risk of cardiac arrest.1 Disparities in both the occurrence of cardiac arrest and the likelihood of resuscitation by witnesses are well known across many characteristics of discrimination. As such, people with different ethnicities, women and obese people are less likely to receive bystander CPR or public access defibrillation use, resulting in less favourable outcomes.2–5
The influence of sex on survival in out-of-hospital cardiac arrest is still under debate even though literature reports a higher survival-to-hospital admission rate in female patients.6–8 Data on survival to hospital discharge and neurological performance are conflicting.9–12 Some studies suggest a better outcome in female patients,6 8 while others show either no survival advantage7 8 11 or higher survival rates in male patients when compared with females.10 12 13 A tendency towards unfavourable outcomes for women remains after adjusting for known outcome predictors such as age or initial rhythm, and some authors have even concluded that male sex is independently associated with improved survival.14–16 The complex underlying factors explaining these differences remain unclear. One explanation could be that women suffering cardiac arrest are significantly less likely to receive potentially lifesaving bystander CPR.9 13 17–21 In addition, there is also evidence indicating that a defibrillator is used significantly less frequently in women.22–24 A recent scoping review on disparities in bystander CPR and education suggested discomfort of laypersons in placing their hands on a woman’s chest as a possible reason.3 Similarly, non-white individuals may be less likely to receive bystander CPR, regardless of their racial or ethnic background or the income level of the neighbourhood where the cardiac arrest occurred.2 4
Resuscitation manikins are designed to train CPR skills and offer the opportunity to practice in a controlled, protected environment. However, most manikins used in CPR training are lean, white and male (or at least male-appearing), and only rarely females, racially diverse or non-lean.1 25 This lack of diversity in manikins might affect the application and effectiveness of CPR in real life and result in a negative impact on clinical outcomes in the respective population subgroups.
The aim of this scoping review was, thus, to identify and describe research evaluating diversified manikins used for layperson Basic Life Support (BLS) education, including self-made adaptations, with the further aim to raise awareness for the problem, provide a basis for stakeholder discussions and encourage further research and innovation.
Methods
Study design
We chose to conduct a scoping review to identify the spectrum of available evidence on adaptations of manikins used for layperson BLS training. Scoping reviews help assess the breadth and nature of emerging evidence in developing areas of practice, particularly when the volume and scope of existing literature are uncertain. The scoping review followed five key stages: (1) formulating the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting the data and (5) collating, summarising and reporting the findings. A specific review protocol to guide this process was created.
Eligibility criteria
This scoping review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for Scoping Reviews.26 (PRISMA checklist available as online supplemental file S1).
Supplemental material
The PICOST question was:
Population: Laypersons or healthcare providers participating in a BLS training or chest-compressions-only CPR
Intervention: BLS training using a diversified manikin (see definition below).
Comparison: BLS training using a male, white, lean manikin (referred to as ‘standard’ manikin).
Outcomes:
Patient/clinical: return of spontaneous circulation, survival to hospital discharge, 30 days survival, 12 months survival, neurological outcome at hospital discharge/30 days
Educational: knowledge acquisition, skills acquisition, willingness to perform CPR, participant satisfaction at the end of the respective course and later (3 months and 1 year).
Study design:
Included studies: Randomised controlled trials and non-randomised studies (non-randomised controlled trials, controlled before-and-after studies, cohort studies and case series n≥5), poster presentations, commentaries and editorials. All languages are included as long as there is an English abstract
Excluded studies: Research on Advanced Life Support training with high-fidelity manikins.
Time frame: Publications from inception to 7 May 2024, with an update on 31 October 2024.
This review focused on CPR manikins used in BLS training and not on the training itself. Therefore, we included accredited BLS training (instructor-led courses accredited by resuscitation councils or rescue organisations) as well as other course curricula. Beside the aim to summarise the current evidence for adaptations of manikins, we also want to map the use of diverse manikins in BLS training. Therefore, we also included observational studies, describing the presence of manikin diversity in educational videos and on social media.
We defined ‘diverse manikins’ as all manikins with any changes compared with a male/flat-chested, white and lean manikin. These adaptations might be modified body shapes (eg, obesity or pregnancy), age (eg, adult, geriatric, paediatric), modified skin pigment (eg, ethnic differences) or gendering the manikin (eg, long hair, make-up, breast tissue to simulate female body features). We refer to the sex of a manikin as different biological and physiological characteristics and therefore how the manikins appear. Within the literature, the terms ‘sex’ and ‘gender’ are used inconsistently and sometimes interchangeably and we therefore aimed to identify both with our search criteria. We took a similar approach to ‘race’ and ‘ethnicity’ as terminology used in published work, while acknowledging the distinction between the concepts.
Information sources and search strategy
The search was conducted on 7 May 2024, with an update on 31 October 2024. The search strategy was developed by two information specialists (CR and BH, Medical University of Vienna, Austria)—see online supplemental file S2. Records from database searches were downloaded and imported in Rayyan (https://www.rayyan.ai/) to facilitate the removal of duplicates and screening. Databases searched included MEDLINE (R) ALL (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), ERIC (EBSCOhost), Web of Science (Clarivate), Infromit, Scopus (Elsevier); and Cochrane Central Register of Controlled Trials (Cochrane Library via Wiley Online). Hand-searching included reference lists of included studies and a keyword search of the social media platform X.
Study selection process
After de-duplication, titles and abstracts were independently screened by two reviewers (CV and SS). Conflicts were resolved via discussion and agreement between the two reviewers. The process was followed by a full-text assessment of the potentially relevant papers by the same two reviewers.
Data charting process, data items, and synthesis of results
Information from selected articles was extracted into a data extraction sheet which included details of the first author, country, publication year, article type, study design, main topics and/or manikin adaptations, participants and the key findings of the studies. Data extraction was reviewed by the coauthors, and disagreements were discussed until consensus was reached.
Results
Study screening and selection
The search found 2719 records, and one additional record was identified through X (former Twitter). After deleting 1444 duplicates, the titles and abstracts of the remaining 1275 records were screened, and 21 articles were entered into full-text assessment. Finally, 15 articles were included for data extraction and analysis (figure 1).
Preferred Reporting Items for Systematic Review and Meta-Analyses flow diagram, created with https://estech.shinyapps.io/prisma_flowdiagram/.51
Study characteristics
The geographical distribution and respective income classifications as per definition of the World Bank are summarised in table 1.27 All included publications described empirical research. All studies were conducted in high-income countries, 60% were published in the last 3 years (n=9) and the first studies (n=2) were published in 2014. 10 publications were original research articles,1 28–36 3 were published as a conference abstract,37–39 1 as a conference poster40 and 1 as a research letter.25
Included studies per geographical region in alphabetical order
Two groups of publications according to the study focus were formed: One analysing effects of diverse manikin use in in-person BLS training including chest-compression-only CPR (11 included studies) (table 2)28–34 37–40; and the other focusing on representation of diverse CPR manikins for layperson education on social media (4 included studies) (table 3).1 25 35 36 An overview of the most important findings can be found in figure 2.
Overview of the results of the included studies.
Included publications analysing different adaptations of manikins for in-person BLS training.
Included publications analysing the diversity of CPR manikins used in educational videos and social media
Effects of manikin diversity
From the 11 studies evaluating different manikin adaptions (totally including 976 participants28–34 37–40), 6 (55%) investigated the influence of manikin sex,29 31 34 37–39 4 (36%) evaluated the effects of an obese manikin28 30 32 33 and 1 (9%) focused on ethnically diverse manikins.40 All of the female or obese manikins represented a white person. Seven studies (64%) adapted a ‘standard’ manikin to produce a diverse manikin (do-it-yourself, DIY-manikin),29–32 34 37 38 two studies used commercially available manikins: one an obese patient28 and the other an ethnically appropriate adult black male,40 but none represented a female patient. One study used a manikin produced by a professional manikin manufacturer, but not commercially available at the time of publication,33 and another study did not specify how they carried out the adjustment.39 All other included studies focusing on the effect of the manikins’ sex reported a DIY adaptation of a ‘standard’ manikin.29 31 34 38 There was a great variability of adaptations to represent a female manikin, ranging from the use of silicone breasts,29 31 34 a wig, make-up, a front-opening brassiere and clothing perceived as ‘typically’ female,29 31 to just small modifications such as a bra under a sweater.38 All studies evaluating the influence of sex had laypersons as participants and reported a variety of outcomes: there was no difference in use of an automated external defibrillator (AED),37 38 the time to first shock38 or bystander CPR initiation.37 Significantly more participants on the male manikin removed clothes completely, and on female manikins female participants removed significantly more often all clothes than male participants. There was greater variability in hand placement during chest compressions on male manikins.29 Two studies evaluating chest compression quality found contrary results, one study had significantly higher appropriate compression depth ratio and significantly lower appropriate recoil ratio on female manikins,31 while in the other one the number of sufficient recoil was significantly higher on female manikins.39 One study discovered greater comfort in performing CPR on women in participants training with a female manikin.34 In one study, the sex of the patient was simulated using virtual reality, while the participants were performing CPR on a ‘standard’ manikin.37
Five of the studies (45%) observed training for healthcare professionals.28 30 32 33 40 Four of these assessed chest compression quality.28 30 32 33 One observed participants’ choice between a standard or a racially diverse manikin for training, and found that for the 78% of participants who identified as black, it was important that they were represented in manikins and that reflecting ethnicity would improve engagement in CPR training.40
Three studies evaluating the effect of body weight of manikins found significantly lower compression depth when performed on the obese manikin.28 32 33 Additionally, participants in one study performing chest compressions on an obese manikin stated they had increased levels of fatigue and pain.32 The use of a device (BariBoard (Iron Duck, Chicopee, USA)) did not change the overall efficacy of chest compressions in an obese manikin.30
The key findings of all the studies are summarised in table 2.
Presence of manikin diversity in educational videos and on social media
Four publications were included in this group.1 25 35 36 Three were cross-sectional studies.25 35 36 One of them25 determined the diversity of manikins represented in social media posts of institutions and organisations, while the other two evaluated diversity regarding race36 and sex35 of characters in CPR training videos. The two studies focusing on CPR training videos included official training videos of the American Heart Association (AHA) and American Red Cross (ARC), as well as videos found on YouTube and Google.35 36 Both studies together included 960 educational CPR videos. One evaluated 86 videos for racial diversity36 and found 3 videos (5% of all manikins) using non-white manikins, but no racially diverse manikins in AHA or ARC instructional videos. Another study screened 874 videos for female manikins and found 10 unique videos (1%) with female manikins. Four of them (0.5% of all videos) were considered high-quality.35
In one study, authors conducted a survey in 56 institutions in North and Latin America to determine the characteristics of manikins used for CPR education.1 They found 12% of adult manikins represented diverse manikins in participating institutions and identified high costs and availability of diverse manikins as the main barriers to use diverse manikins.
Table 3 summarises the key findings.
Discussion
This scoping review identified 14 publications addressing CPR manikin diversity for BLS training, published between 2014 and 2024. Due to the heterogeneity of the covered topics, we did not conduct a systematic review. Issues addressed were the quality of chest compressions in obese manikins, assessing laypersons’ responses to a cardiac arrest based on the victim’s sex including removing clothes, AED use, and hand placement, and the participants’ choices of manikin between a standard manikin or a dark-skinned manikin.
Bystander CPR rate and survival rates after cardiac arrest in black communities have in the past been reported to be lower than in other communities.2 However, only four studies included in this review (three were observational1 25 36) reported on racial diversity of CPR manikins.1 25 36 40 Only one of them evaluated the use of non-white manikins (an adult black male with anatomically adapted features).40
Most currently commercially available dark-skinned manikins do not accurately reflect the differences between white and other ethnicities, as they are simply differently skin-coloured manikins.41 Specific ethnically diverse manikins developed together with respective population groups could possibly improve further tailored resuscitation education, with the potential to increase engagement and willingness to help in these groups.40 42 43 For instance, CPR teaching participants self-identifying as black stated that manikin reflecting ethnicity would improve engagement in CPR training.40
Surprisingly, only two studies used commercially available manikins,28 40 and none of these were female. The reason behind that could be non-availability with manufacturers or too high costs for CPR mass education. This assumption is reinforced by a survey conducted among organisations teaching CPR, in which the most significant reported barriers were cost and availability of diverse manikins.1 A novel way to overcome the lack of availability could be the use of new technologies like augmented or virtual reality. A recently published study tested a virtual reality system simulating a female patient and providing visual and physical feedback.44 Although these technologies have already found their way into many medical fields including CPR education,37 45–47 there are still significant barriers such as required resources and implementation before they can be broadly available.
Sex-diverse CPR manikins could familiarise rescuers with CPR on women and might reduce barriers towards chest compressions, which could finally increase the possibility of survival for women in cardiac arrest.34 Furthermore, concerns about inappropriate touching of women’s breasts, accusations of sexual assault and fear of causing injury by starting bystander CPR in women18 could be specifically addressed during the CPR training.
Until affordable diverse CPR manikins are available, CPR training organisations might create their own diverse DIY manikins. An online tutorial estimates the costs to adapt a ‘standard’ manikin to a female manikin to be about US$6,48 and a recently published scoping review provides an overview of DIY devices for layperson CPR training.49
Gaps of knowledge and action points
The educational impact on patient survival using different diverse manikins during CPR training is unknown. The degree of fidelity and to which detail manikins need to be adapted are unclear. Properly powered high-stake studies to answer these two knowledge gaps are certainly needed.
Also, CPR training organisations and instructors need to raise awareness for sociodemographic disparities in CPR outcomes. The use of ‘standard’ manikins for CPR training stands in a wide context of implicit bias, which is unconscious and unintentional mental associations that impact our understanding and actions. Implicit bias is often difficult to recognise and to address during teaching. To reduce inequities in training, there are some evidence-informed teaching tips and strategies regarding recognition of implicit bias and management for medical educators described in the literature.50 As resuscitation education becomes more sophisticated, the idea of a white, male, lean manikin as the only manikin used should be abandoned in favour of manikins reflecting the diversity of the communities. All stakeholders involved in resuscitation education should contribute to the solution.
Limitations
Four of the included studies were only available as an abstract. Five of the included studies included healthcare providers as participants, which could influence the findings. However, since they should be trained regularly, the confounding effect of previous training should be less than in laypersons, and findings should reflect the influence of the manikin. In addition, a simulation or resuscitation setting itself is a familiar situation for healthcare providers. Also, only a limited number of studies report on the diversity of manikins during CPR training and no published work reflects the view from low-resource settings. However, in such settings, other healthcare problems that need to be addressed might have a higher priority. The authors’ list of this scoping review is not as diverse as potentially possible, which might have conveyed biased views.
Conclusion
This scoping review provides limited evidence on the effect of the use of various diverse manikins (eg, concerning race, sex, age, body shape) for CPR education. The often-used white male manikins do not represent the diversity of communities trained in CPR or suffering cardiac arrest. The vast majority of found studies reported on adaptations of manikins in a do-it-yourself way to generate different diverse manikins. The most prominent reported barrier to not using diverse manikins was high costs and availability of such manikins. Using diverse racial manikins has the potential to improve engagement in CPR training in population subgroups with the aim to increase survival of cardiac arrest. Such manikins can raise awareness of sociodemographic disparities in CPR outcomes during training and reduce barriers to not helping.
Data availability statement
Data are available upon reasonable request. Data will be made available upon reasonable request due to national and organisational law.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The authors acknowledge the assistance provided by the information specialists of the Medical University of Vienna, Birgit Heller and Caroline Reitbrecht, for building the searching strategy.
References
Footnotes
Handling editor Kirsty Challen
X @ffsemeraro
Contributors CV: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation, Visualisation. BS: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. SH: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. AK: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. SO: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. EB: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. ES: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. NEA: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. SN: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. JS: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. ZA-H: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. MTM: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. MK: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. FS: Writing—review and editing, Writing—original draft, Methodology, Data curation, Conceptualisation. TG: Writing—review and editing, Writing—original draft, Methodology, Data curation, Visualisation, Validation, Supervision, Project administration, Conceptualisation. SS: Writing—review and editing, Writing—original draft, Methodology, Data curation, Visualisation, Validation, Supervision, Project administration, Conceptualisation. SS is responsible for the overall content as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests CV is member of the Young European Resuscitation Council (ERC) committee. SO is Secretary of the Austrian Resuscitation Council (ARC). NEA was International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams (EIT) Task Force member. SN is ILCOR EIT Task Force member, and ERC Instructor-Educator-Support Science and Education Committee member. JS is Chair of the ARC. FS is President-Elect of the ERC. TG is Chair of the ILCOR EIT Task Force and ERC Director of Guidelines and ILCOR. SS is ILCOR EIT Task Force member, ERC Advanced Life Support Science and Education Committee member, and Vice-Chair of the Austrian Resuscitation Council.
Provenance and peer review Not commissioned; externally peer reviewed.
Preregistration https://www.medrxiv.org/content/10.1101/2025.02.03.25321593v1
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.