Archives of Academic Emergency Medicine. 2019; 7(1); e4 OR I G I N A L RE S E A RC H Continuous Education of Basic Life Support (BLS) through Social Media; a Quasi-Experimental Study Seyyed Mahdi Zia Ziabari1, Vahid Monsef Kasmaei1, Lida Khoshgozaran1∗, Maryam Shakiba2 1. Department of Emergency Medicine, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. 2. Guilan Road Trauma Research Center, School of Health, Guilan University of Medical Sciences, Rasht, Iran. Received: September 2018; Accepted: October 2018; Published online: 20 January 2019 Abstract: Introduction: It is imperative, if not fundamental, for medical students to receive continuing education in Basic life support (BLS). This present study aimed to investigate the effectiveness of continuing education using social media in this regard. Methods: In this quasi-experimental study, a questionnaire containing 20 items about BLS awareness was completed by the interns who were trained monthly in the emergency medicine training course. Then half of the interns received distant education through Telegram software up to three months, and the other did not receive any further education. Again, both groups completed the questionnaire at the end of the third month. Results: 100 medical interns with the mean age of 25.05 ± 1.26 years were allocated to two groups of 50 subjects (65.0% female). Two groups were similar regarding the mean age (p = 0.304), gender (p = 0.529), mean awareness score at the beginning of the study (p = 0.916), and average pre-internship exam score (p = 0.080). The mean awareness score of medical interns increased significantly in intervention (11.44 ± 2.37 to 14.88 ± 1.97, p < 0.0001) and control (11.38 ± 3.22 to 12.54 ± 3.04, p < 0.0001) groups at second examination. But mean difference of awareness score, before and after the education, was significantly higher in intervention group (3.44 ± 1.48 versus 1.16 ± 1.51; p < 0.0001). Conclusion: The increase in the BLS awareness score was significantly higher in medical interns who were continuously educated using Telegram social media software. Keywords: Education; cardiopulmonary resuscitation; mobile application; computer-assisted instruction Cite this article as: Zia Ziabari SM, Monsef Kasmaei V, Khoshgozaran L, Shakiba M. Continuous Education of Basic Life Support (BLS) through Social Media; a Quasi-Experimental Study. Arch Acad Emerg Med. 2019; 7(1): e4. 1. Introduction Despite many advances in medicine, sudden cardiac arrest remains a leading cause of death in most countries world- wide (1). Subsequent outcomes of cardiac arrest depend on basic measures such as chest compression, defibrillator, and more advanced actions (2). The importance of cardiopul- monary resuscitation (CPR) has been well documented, so that a good CPR can reduce mortality up to 50% (3). In gen- eral, the ability to diagnose and treat a respiratory or cardiac arrest is a basic medical skill that all health care providers including medical students should have these skills. They should learn to carry out CPR and pre-hospital activities and increase their skills during educational courses (4, 5). The measures for basic life support (BLS) for adolescents outside ∗Corresponding Author: Lida Khoshgozaran, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. E-mail: Lida.khoshgozaran@gmail.com Tel: 00989111414384 the hospital include rapid detection of cardiac arrest, quick activation of the emergency medical services (EMS), pulse check, CPR, and rapid defibrillation with an automated ex- ternal defibrillator (AED) (6). Since the quality of CPR de- pends on the learner memorizing and applying the scientific and practical skills, continuing education should be provided in this regard (7). The use of e-learning in medical educa- tion has had good results and has been effective (8, 9). In this way, electronic tools and software are used as a means to improve learning, communication and interactions, and increasingly to train medical professionals (10, 11). The ad- vancement in e-learning technology and the use of comput- ers and online training has made it possible to save costs and transfer data without any time limit. Also, the person- to-person training capabilities meet the learner’s needs well (12, 13). Although the BLS course is held every two years, re- searches have shown that quality of BLS clinical skills begin to decrease after 3 months (14-16). Studies showed that the students had more tendency and self-confidence to perform CPR after multiple educational sessions (17, 18). Researches This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem SM. Zia Ziabari et al. 2 Figure 1: Mean awareness score in intervention and control groups before and after the education (p < 0.0001). have also shown that watching an educational video clip on cell phone to remind and review BLS content increases the skill and self-confidence to carry out CPR and the use of AED in rescuers (18). Considering the above mentioned, we de- cide to investigate the effectiveness of continuous education of BLS through social media (Telegram software) on medical interns. 2. Methods 2.1. Study design and setting This quasi-experimental study, was conducted on medi- cal interns who were trained monthly in the emergency medicine training course of Poursina Hospital, Rasht, Iran, from August 2016 to July 2017. All medical interns entered the study with informed consent, and reviewing the research project was carried out by the Ethics Committee of the Re- search Unit of Guilan University of Medical Sciences (IR. GUMS.REC.1396.69). the study was registered in Iranian Reg- istry of clinical trials with number: IRCT20110818007369N5. 2.2. Participants All medical interns who were passed the one month emer- gency medicine educational program in mentioned hospi- tal during the study period were enrolled. Dissatisfaction with continuing to participate in the study, lack of access to smartphone, not using of Telegram software were among the exclusion criteria. There was no any sex or age limitation. The medical interns were given an ethical commitment that their personal information would remain confidential and they also gave a moral commitment to not share the contents of the classroom and the software until the end of the study with other interns. 2.3. Data gathering To assess the students’ awareness regarding the BLS at the beginning and end of the study, a questionnaire containing 20 items was used (19). The Persian version of this question- naire was translated into English, and it was again translated into Persian by a native. To determine the quantitative va- lidity, content validity ratio (CVR) and content validity index (CVI) were used. The score for cut-off point in Lawshe table for 10 experts was 0.62. In the questionnaire, the CVR scores of all questions were 0.8 to 1, which is confirmed in terms of CVR index. Also, in terms of the CVI, the lowest CVI was 0.7 and its maximum was 1 in the three dimensions of relevance, simplicity and clarity. Therefore, questions with a CVI of be- tween 0.7 and 0.8 were subject to partial review, and the re- maining questions due to the high CVI remained unchanged. To determine the internal consistency of the questions, the Richardson coefficient 20 was used, with the obtained alpha value equal to 0.996 (more than 0.7), indicating the internal consistency of the questions in the calculation of students’ awareness to the BLS algorithm. 2.4. Intervention Mentioned questionnaire was first distributed among med- ical interns, and they were asked to answer the questions based on their information and to enter data including their name, age, gender, and average pre-internship exam score in the questionnaire. Based on the answers to the questions, a score of 1-20 was attributed to the students (correct answer to each question had 1 score, the wrong answer was zero, and negative score did not belong to the wrong answers). The scores obtained from the questionnaire were gained with al- gebraic scores from each question (zero or one), and the stu- dents’ awareness was measured based on these scores. After completing the questionnaire, all of the interns received an in-person tutorial using PowerPoint software by the teachers of Rasht Poursina hospital, and an emergency medicine res- ident, based on the 2015 AHA educational guideline on BLS for adults and children (1, 6, 20-22). After being trained at the hospital, half of the interns who were selected sequen- tially and non-randomly, received distant continuing educa- tion for up to three months through social media (Telegram software, which is comprehensive and accessible in Iran). This training was conducted in a person-to-person manner by sending abstracts of taught materials in the classroom based on the 2015 AHA guidelines, which was presented in short texts, photographs and educational videos related to how to perform BLS. The other half of the participants did not receive any further training after the in-person education offered at the hospital. Then, at the end of the third month af- ter holding the first in-person class, both groups received the questionnaire through the Telegram software, and the aware- ness on BLS was measured by refilling the same question- naire. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2019; 7(1); e4 Table 1: Basel line characteristics of case (continuous education with social media) and control (regular education) groups Variable Value P values Gender (male/female ratio) Case 31/19 (1.63) 0.529 Control 34/16(2.12) Age (year) Case 24.92 ± 1.01 0.304 Control 25.18 ± 1.46 Awareness score Case 11.44 ± 2.37 0.916 Control 11.38 ± 3.22 Pre-internship exam score Case 15.97 ± 0.81 0.080 Control 16.24 ± 0.71 Data are presented as mean ± standard deviation. 2.5. Statistical Analysis We calculated sample size using altman monogram with α: 0.01, β: 0.2 and d2: 0.9. The allocation ratio was 1:1, and finally 50 students entered in each group. Data were anal- ysed using mean and standard deviation. Normality of data was evaluated using skewness and kurtosis indices. Paired t- test and independent t-test were used to compare means be- tween the groups. All analyses were performed in SPSS ver- sion 19 and a significant level was considered as below 0.05. 3. Results 119 medical interns were studied. 19 out of 119 students were excluded (3 were not using the Telegram software, 4 were not satisfied to participate to the study, 12 did not fill the ques- tionnaire after 3 months). Finally 100 medical interns with the mean age of 25.05 ± 1.26 (23 - 31) years were allocated to two groups of 50 subjects (65.0% female). Table 1 com- pare the baseline characteristics of two groups. Two groups were similar regarding the mean age (p = 0.304), gender (p = 0.529), mean awareness score at the beginning of the study (p = 0.916), and average pre-internship exam score (p = 0.080). The mean awareness score of medical interns increased sig- nificantly in intervention (11.44 ± 2.37 to 14.88 ± 1.97, p < 0.0001) and control (11.38 ± 3.22 to 12.54 ± 3.04, p < 0.0001) groups at second examination (figure 1). But mean differ- ence of awareness score, before and after the education, was significantly higher in intervention group (3.44 ± 1.48 versus 1.16 ± 1.51; p < 0.0001). 4. Discussion The findings of this study showed that the increase in the BLS awareness score was significantly higher in medical in- terns who were continuously educated using Telegram social media software. An interventional study by Khorasani et al. showed that the mean score of awareness and practice before and after the primary emergency care education workshops indicated a significant difference in practice before and af- ter taking part in workshop in dentistry interns (23). Ji Yun Ahn et al. showed that watching an educational video clip in cell phone in order to remind and review the BLS mate- rials increased skill and self-confidence to perform CPR and using AED in rescuers after three months (18). In our study, the impact of this continuous education was seen positively, although there was no need to use a memory card and a re- minder message to view clips and educational pictures, and all interns could have enough time to read, understand, and answer person-to-person questions using Telegram software within three months. In a randomized controlled trial, Eric L. Einspruch et al. in the United States, compared memoriz- ing CPR skills in conventional education to teaching through 22-minute self-learning videos. In both groups, the decrease amount in skills after two months was generally the same. In the second assessment two months later, the subjects of the self-learning group were better than the conventional group in all skills, except for the emergency call, which were the same for both groups. In the assessment with manikin, the self-learning group was better than the conventional train- ing group in the ventilation volume, but both groups per- formed equally in proper hand positioning in chest compres- sion and massage depth (7). Contrary to this study showing a decrease in skills after two months, the awareness of interns’ after three-month continuing education did not reduce, but increased significantly compared to the control group in our study. In general, the ability to diagnose and treat a respi- ratory or cardiac arrest is a basic medical skill that all med- ical students should have the skills. They should learn CPR and pre-hospital activities and increase their skills during ed- ucational courses (4, 5). Given that these skills and aware- ness about how to conduct appropriate BLS are forgotten over time, and according to AHA 2015, studies have demon- strated that deterioration of BLS skills in as little as 3 months after initial training (14-16), therefore, it should be empha- sized that in order to maintain and improve clinical skills, they need to be adequately memorized with repeated train- ing (7). With the help of information and communication technology capabilities, students are able to provide infor- mation at any time and place quickly. The learner can have enough time to read, understand, and answer the questions in a person to person manner, in spite of his/her work, fam- ily, disability and geographical location; this encourages and motivates him/her (24). Considering the widespread use of modern Telegram software in society especially in the stu- dent population, this study examined the effect of person to person and continuing education of CPR operation using Telegram among medical students. Since all students were spending their internship in different parts, the software pro- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem SM. Zia Ziabari et al. 4 vided continuous communication with each other. 5. Limitation The weaknesses of this study were the lack of randomiza- tion and the impossibility of blinding due to the nature of the study, and the lack of facilities for examining the practical skills of students at the same time. Since it is not possible to examine skills in addition to knowledge, it is suggested that future studies consider these two issues together. 6. Conclusion The results of this study indicate the positive effect of con- tinuing education of BLS through Telegram software on the awareness of medical students. This finding can demon- strate the positive role of using modern communication net- works and the possibility of using them in the student com- munity. 7. Appendix 7.1. Acknowledgements This research was supported by Guilan Road Trauma Re- search Center. We thank our colleagues from Rasht Poursina hospital who provided insight and expertise that greatly as- sisted the research. 7.2. 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