The present study took place in Brandenburg, a large German territorial state, which surrounds the capital state of Berlin. The study was part of the initiative “Jeder kann ein Held sein” [“Everyone can be a Hero”], which was started by medical students and paramedics of the honorary volunteer organization Pépinière in Germany. Its aim has been to improve schoolchildren’s education and practical training in basic first aid and resuscitation.

We included six primary schools that were on a list provided by the Brandenburg school authority from across the state on a first-come, first-served basis. The training program was delivered during regular school hours, thus all children had to be present in the classroom. However, participation in practical first aid exercises and in role-play activities was voluntary.

In a pretest study, we evaluated the feasibility of the newly developed first aid program in one primary school and its acceptance among children, parents, and teachers. The program was highly accepted by children and parents, while recommendations by teachers led to the inclusion of more practical methods, especially for children aged 6–8 years.

Ethical approval for the evaluation was obtained from the review board of the Charité – Universitätsmedizin Berlin, Berlin, Germany (application number: EA2/123/18).

From six primary schools in Brandenburg, we included all present grade 1–6 students, ranging from age 6–13 years. We also included children with insufficient German language skills (from immigrant or asylum-seeking families). Children who missed the baseline assessment on the first day were excluded from the evaluation. The number of children per classroom was similar across the six schools. In the first two grades, there were about 15–22 children (mostly aged 6–7 years) in each classroom, whereas in grades 3 to 6 the number was higher with about 22–28 children.

The standardized 2-day program was taught in the students’ classrooms while the teachers were present. The course took place during regular primary school days, which last between 4–6 hours in German public primary schools. Younger primary school students aged 6–8 years old usually do not have lectures for more than 4 hours (each is 45 minutes long). The course lasted 4 hours per day including regular breaks. Grades 3 to 6 (i.e., children aged 8–13 years) have usually up to 6 hours per day. After the 4 hours of the first aid course, they discussed general health-related topics with their teachers during the fifth and sixth hours in school.

The module-based lesson plan of our first aid course is presented in Table 1. The interactive problem-based learning-oriented modules focused on four main areas of first aid: scene safety-protection measures, general bleeding control, and compression bandage application (Figure 1), recovery position, and resuscitation in a standardized curriculum (Table 1). The modules included many practical exercises and role-play/case studies, considering the different age groups of the children.

For the 2 days, the instructors had to follow a standardized module-based lesson plan with detailed learning goals. Each instructor had a standardized box containing various first aid training materials. It included bandages, a high-visibility waistcoat, a safety triangle, disposable medical exam gloves, at least three cardiopulmonary resuscitation (CPR) manikins, a blanket for practicing the recovery position, disinfection, and a model of a head to demonstrate how to tilt the head.

As recommended in guidelines of first aid education for children (De Buck et al., 2020; Global First Aid Reference Center, 2020) the instructors engaged the children to come up with their own scenarios, used age-appropriate role-plays but also informed the students on the importance to help in case of need and on a very basic level about physiology, but totally avoided any over-medicalized terms or medical language. The instructors only used age-appropriate language, which was adapted to individual children’s experiences. Our curriculum was based on and aligned with those from two established rescue organizations, the German Red Cross, and the Arbeiter-Samariter-Bund [Workers’ Samaritan Federation], a large German aid and rescue organization.

As the focus of our evaluation was to assess the benefits of first aid in primary school students of any age, we also included children aged 6 and 7 years, although they are not specifically included in recommendations by International First Aid, Resuscitation and Education Guidelines of the Federation of Red Cross and Red Crescent Societies in 2020. (Global First Aid Reference Center, 2020).

The content of the course was taught in an age-specific fashion. For children aged 6–7 years, we kept the explanations as simple as possible and focused on practicing with a playful approach. In children aged 8–13 years, age-specific more advanced explanations (e.g., regarding the physiology of important organs) were included. Songs and manikins were used throughout all age groups. De Buck and colleagues’ recent guidelines with recommendations for the most appropriate age-specific teaching methods were published in 2020, after our study. Fortunately, we found many of their recommended elements that we also used in our training course, such as games and songs for the younger children and case studies and role-plays for the older children (De Buck et al., 2020; Global First Aid Reference Center, 2020).

For the resuscitation training, we used the cardiopulmonary resuscitation exercise manikin “Mini-Anne” (by Laerdal Medical, Stavanger, Norway). We had a total of 50 Mini-Annes, which did not provide feedback (for electronic recording). The manikins were used for teaching as well as for the post-course practical skill assessments, which were evaluated through observation by the instructors. Mini-Anne has a click mechanism that we deactivated on purpose during the course and during the evaluation of practical skills to minimize disappointment due to physical strengths.

In the present study, we had three main instructors with several years of working and teaching experience with rescue organizations (PH, RG, AN), who planned and coordinated the courses. They selected, trained, and supervised a pool of 20 instructors for the present project. All instructors were advanced medical students and nurses who were specially trained in basic life support and first aid and/or were certified emergency medical assistants (paramedics). They worked for the project on a voluntary basis without any payment. According to the number of classes in each school, the number of instructors varied. In the larger primary schools (C, D and E) up to twelve instructors were conducting the training. A core team of eight to 10 instructors taught in all six schools of this project, whereas the remaining were substitutes for those who had other obligations on the day of the course or were sick.

The week or the evening before participating for the first time in the project, the new instructors were informed in a group setting or on an individual basis by one of the three main instructors about the module-based lesson plan (including hand-outs), the specific goals and core elements of each module including mnemonics and other specific tips (Table 1). In addition, instructors sat in and assisted during a first aid course taught to primary school students by another instructor before they started to teach themselves.

For this project, all course modules were taught by at least one instructor in each class, always in the presence of the class teacher, as the course took place during regular school hours. On all days, at least two of the three main instructors were present in the schools. On the morning of the first day, one hour before the first lesson started, the main instructors met in the school with all instructors and the teachers to organize the agenda for the next two days and the evaluation on the third day. During the course, the main instructors were always available for giving advice if required by the other instructors. During the scheduled breaks, all instructors came together in the central coordination room that was provided by each school and discussed possible questions that may have come up in the classroom.

The baseline (i.e., pre-intervention) knowledge assessment was conducted using a questionnaire with standardized questions and basic socio-demographic questions. It took place in the classroom on the first day of the course before the first lesson started. We assessed the post-intervention knowledge evaluation on day three (i.e., the next day after the course) in the classroom before the practical skills evaluation started. The age-specific questions were generally simple and according to the students reading and writing skills.

The baseline questionnaire for this age group assessed basic demographic information (age in years, gender identity, and the language spoken at home: “only German,” “mostly German,” or “mostly non-German”). The pre-intervention knowledge evaluation examined the knowledge of the emergency number (free text field), willingness to help others who are in an emergency (in four categories: “I would help everybody,” “I would help only someone I know,” “I would not help at all,” or “I am not sure”), and whether they had attended any prior form of first aid training (yes/no). The post-intervention knowledge evaluation included seven main questions. In addition to the baseline questions on an emergency number and willingness to help others in an emergency, we asked the children what module of the course they liked most (free text field). The assessment of their knowledge of basic resuscitation methods included compression depth (correct answers in free text fields included “4–6 cm,” “4 cm depth,” “1/3 depth-ratio,” “as deep as possible,” or “until cracking in manikin”), hand placement (marking the middle of the chest in the drawing of a person), and compressions per minute (correct answers in free text fields included “100–120 per min,” “2 per sec,” “a song with 4/4 beats (120 beats/minutes),” or “very fast”; the latter only until the age of 9 years) according to the current European Resuscitation Council (ERC) guidelines at the time (Olasveengen et al., 2021).

For this age group, an instructor read each question aloud. If 6-year-old students had difficulties in spelling, the teacher assisted them throughout the evaluation.

The pre-intervention evaluation and questionnaires of this age group included 10 questions. Apart from age (in years), gender identity, the language spoken at home (“only “German,” “mostly German,” or “mostly non-German”), previous first aid courses (yes/no), and knowledge of the emergency number (free text field) the students were asked about the willingness to help others in an emergency (“I would help everybody,” “I would help only someone I know,” “I would not help at all,” or “I am not sure”). Students answered questions concerning general knowledge of self-assessed first aid skills including compression bandage (“Do you know how to put on a compression bandage?” by yes/no), and recovery position (“Do you know how to put someone in the recovery position?” by yes/no).

Furthermore, we asked about previous knowledge of resuscitation including the compression point (i.e., hand placement by marking the middle of the chest in the drawing of a person), compression depth (correct answers in free text fields included “4–6 cm,” “4 cm depth,” “1/3 depth-ratio,” “as deep as possible,” or “until cracking in manikin”; the latter two only until age 9 years. And the rate of chest compression (correct answers in free text fields included “100–120 per min,” “2 per sec,” “a song with 4/4 beats (120 beats/minutes),” or “very fast”; the latter only until the age of 9 years.

The post-intervention knowledge evaluation with 10 questions included assessments of what students liked about the course, willingness to help others (“I would help everybody,” “I would help only someone I know,” “I would not help at all,” or “I am not sure”), and knowledge of the emergency number (free text field). Short descriptions of emergency scenarios followed. The cases dealt with bandaging, recovery position, and resuscitation methods. Students had to answer in free text fields with keywords or a sentence. The last four questions were the same as in the pre-intervention evaluation assessing knowledge of resuscitation methods.

On the third day, students were evaluated in terms of their practical skills at various stations. The three main instructors of the project (PH, RG, and AN) explained the assessment criteria for each exercise to the individual instructors beforehand, pointed out the importance of always giving positive and if necessary constructive corrective feedback to the children (after the exercise was over) and supervised the instructors during the assessments.

The instructors assessed the recovery position, compression bandage application, and resuscitation methods using a standardized form. The performance in the task “compression bandage” was assessed on a 4-point Likert scale with (i) correct (i.e., tight), (ii) technique mostly correct, (iii) insufficient, or (iv) not done (e.g., if a child felt unwell, refused to participate in the evaluation of this exercise, or was excluded by the teachers for a matter unrelated to the intervention).

The performances in the task “recovery position” were assessed on a 4-point Likert scale with (i) correctly conducted with all components, (ii) mostly correct, (iii) insufficient, and (iv) not done (e.g., if a child felt unwell, refused to participate in the evaluation of this exercise, or was excluded by the teacher for a matter unrelated to the intervention).

The assessment of the resuscitation exercise was done visually by the evaluator who recorded the depth and rate of chest compression (both on a 4-point Likert scale for compression depth: (I) compression sufficient (which was defined as 5–6cm), (ii) compression depth close to sufficient, (iii) compression depth insufficient and (iv) not done). For compression rate: (I) sufficient (defined as 100–120/min), (ii) mostly sufficient, (iii) insufficient, and (iv) not done (e.g., if a child felt unwell, refused to participate in the evaluation of this exercise, or was excluded by the teacher for a matter unrelated to the intervention).

Our evaluation of the first aid training program followed an exploratory analysis approach rather than testing specific primary and secondary hypotheses. No formal level of statistical significance was set. The distribution of age as a continuous variable was described by median, interquartile range, minimum and maximum, whereas distributions of categorical basic sociodemographic variables (gender identity, main language spoken at home, and previous participation in a first aid course) were reported using absolute and relative frequencies (percentages). The latter was reported with corresponding 95% confidence intervals (95%-CI) as a measure of statistical uncertainty.

The main analyses were conducted after stratification in 2-year age categories (6–7, 8–9, 10–11, 12–13 years) using absolute and relative frequencies; the latter as percentages with the corresponding 95%-CIs based on bootstrapping technique (statistical software IBM SPSS Statistics 27). We compared the outcome variables “willingness to help” and “students’ knowledge of first aid including emergency number(s) and elements of resuscitation” before and after the 2-day course. The outcome variables assessing practical skills (i.e., compression bandage, recovery position, and resuscitation parameters) were only assessed post-course.

In six primary schools in the state of Brandenburg, 1,340 students with an age range of 6–13 years participated in the first aid courses. Of them, 1,268 reported their age on the questionnaires and were included in the age-specific analyses. About 16% of the students did not speak German at home (alone or in addition to German). In one school, over half of the children had some previous first aid training, whereas in all other participating schools this experience ranged from 11%–39% (see individual confidence intervals, Table 2). To examine if this may have had an effect, we conducted additional analyses stratified by school. They showed that the schools with a higher percentage of children reporting previous first aid training did not perform better regarding knowledge and skills than schools with a lower percentage (data not shown).

Most of the students already knew the emergency number(s) prior to the course (Figure 1). This proportion increased considerably after the course only in children aged 6–7 years but remained at around 90% in those aged 8–13 years (Figure 2).

Prior to the course, 56% to 73% of the children of different age groups would have helped everyone in an emergency (not only persons they have known before). After the course, the proportion of those helping everyone in an emergency increased further in all age groups, particularly in the two older age groups (Figure 3, Table 3).

Before the course, only 13%–15% of the children aged 8–13 years reported knowing how to do a compression bandage. The proportion of those claiming to know how to put someone in the recovery position ranged from 19%–30%, whereas for resuscitation techniques this proportion ranged from 14%–18% (Table 4).

Before the course, very few children had any resuscitation knowledge regarding correct hand placement, correct depth, and rate of chest compression. After the training course, the post-intervention evaluation assessment showed strong improvements in all resuscitation parameters, particularly in the three older age groups. Most of the children aged 8–12 years answered basic resuscitation questions correctly (Figure 4).

After the course, the assessment of practical skills showed that overall, about three-quarters of participating children were able to apply a compression bandage correctly or almost correctly. On average, the performances seemed best in the 8–11-year-old children comparing the point estimates with those of the other children (Table 5).

About three-quarters or more of all children performed the recovery position correctly or almost correctly. There were no considerable differences between the age groups (Table 5). The proportion of students who performed a “sufficient or close to sufficient compression depth” increased by age, whereas the “compression rate during resuscitation” was assessed as sufficient or close to sufficient in about 80% of the children aged 8–13 years compared to about 60% in the 6–7-year-olds (Table 5).

Although most primary school students already knew at least one emergency number, the participation in the first aid course increased this proportion to almost 80% (students aged 6–7 years) and around 90% (8–13 years). The attitude to help in the case of an emergency increased slightly after the first aid course in students aged 6–7 years, whereas we saw much stronger increases in those aged 8–13 years.

Most students aged 8–13 years showed appropriate first aid knowledge and practical skills including basic resuscitation techniques after the 2-day training course, whereas first aid knowledge improved to a lesser extent in those aged 6–7 years. Among the latter, over 50% performed the exercise “compression bandage” and “recovery position” successfully in the final practical skill assessments, whereas less than half were able to demonstrate sufficient/almost-sufficient basic resuscitation skills.

Earlier studies included smaller samples of kindergarten and primary school children than our study with over 1200 children aged 6–13 years (Banfai et al., 2017; Bollig et al., 2009; Bollig et al., 2011; Calicchia et al., 2016; Fleischhackl et al., 2009; Lubrano et al., 2005; Calicchia et al., 2016). A previous study that evaluated first aid and resuscitation instructions including very young school children was conducted by Austrian emergency physicians who studied 47 students aged 6–7 years. Most children knew an emergency number, were able to perform the recovery position, and used a defibrillator after their newly developed 1-week program. However, the effects regarding the care of burn injuries and cardiopulmonary resuscitation were only mediocre. Finally, 82% of all parents considered their children capable of reacting properly in emergency situations (Uray et al., 2003).

A 3-day course, comparable to our 2-day program, was evaluated in over 500 children aged 7–14 years in Hungary. Their findings were confirmed by our results showing considerable gains in knowledge and practical skills in all age groups. However, we did not see such a strong age gradient in all assessments as in the Hungarian study (Banfai et al., 2017). In our post-course assessments, the knowledge and skills of the students aged 6–7 years were not as good as those in the older student groups. However, those aged 8–9 years performed sometimes on a quite comparable level to students aged 10–13 years.

In some practical assessments, the 10–11-year-old students seemed to have performed better than those aged 12–13 years (Table 5). It has been speculated by some teachers that this may be due to puberty and lack of concentration. However, overlapping 95%-confidence intervals between these two age groups did not indicate clear differences (e.g., among the 10–11-year-old students the application of a compression bandage was correctly or almost correctly performed by 81% [77%–85%] compared to 74% [65%–82%] among the 12–13-year-old ones). Similarly, the recovery position was correctly or almost correctly performed by 89% [86%–92%] and 90% [83%–95%] of the 10–11- and 12–13-year-old students, respectively (Table 5). Larger samples of 12–13-year-old students than in our study would be necessary to examine possible differences in this preadolescent age period.

In the past, studies with primary school children were mostly not as comprehensive as our study regarding the first aid topics and skills covered (Lubrano et al., 2005). Previous studies often focused only on CPR (Bohn et al., 2012; Li et al., 2018; Lukas et al., 2016) whereas we also taught and evaluated basic first aid skills such as general behavior including scene safety, applying the recovery position and compression bandages. Fleischhackl et al. (2009) reported that 86% of included students with a mean age of 13 years (range 9–18 years) performed CPR correctly but did not report age-specific results. In comparison to Fleischhackl and colleagues, we found a slightly lower percentage with about 80% correctly or almost correctly performing chest compression for children aged 10–13 years. For the age group 8–9 years, this percentage was considerably lower with one-third performing chest compression insufficiently (Table 5).

The age of students is determining the effectiveness of a first aid course, especially their practical resuscitation skills (Banfai et al., 2017; Plant & Taylor, 2013; Bohn et al., 2012). For physical reasons, very young students were not able to perform CPR as well as teenagers or adults in terms of “push hard and fast.” However, starting to teach these techniques before puberty, even in the first school years, may improve self-confidence, motivation, and skills to help them later in life (Banfai et al., 2017; Bohn et al., 2012).

A British study showed that students aged 9–12 years chose the correct hand placement and the correct compression rate during CPR, however, they did not achieve the correct depth of chest compressions as adults usually do (Jones et al., 2007). This was confirmed by an Austrian study with 8–13-year-old children. Nevertheless, over 98% of all 322 children participating in that study had fun and interest in the training and 90% of all age groups wanted to continue to receive resuscitation training in the future (Weidenauer et al., 2018). A German study with 1,022 participating 10–17-year-old students found that the necessary force to compress the chest in accordance with the ERC guidelines can only be applied by children aged 12–13 years and older (Rücker et al., 2010).

On the contrary, two studies found some evidence that 10-year-old children may be able to understand and/or perform chest compressions with adequate depth of pressure (Lukas et al., 2016; Abelairas-Gómez et al., 2014). The evaluation of 10–15-year-old children showed that many were able to improve their practical skills in basic life support, however, the majority were not able to perform CPR as well as adults (Abelairas-Gómez et al., 2014). Our results suggested that students aged 8–13 years might gain similar levels of resuscitation knowledge by a single session in comparison to older students. This is further evidence for recommending mandatory age-specific first aid lessons including basic life support beginning in early primary school age.

The participation of children in first aid courses and especially resuscitation exercises regardless of the effectiveness of the training can also increase the general willingness to help in an emergency, as two Japanese studies have shown (Hori et al., 2016; Kitamura et al., 2016). Similarly in our study, the willingness to help increased among all students after the course, especially among the older children. We did not assess the reasons why some children (i.e., ranging from 0%–3% depending on the age group) were still not willing or were unsure to help (Table 4). It may be due to strict parental advice to stay away from strangers or being afraid to cause more harm while helping the person in an emergency as suggested in a study from Croatia with 12–15-year-old youths (Petrić et al., 2013). Studies including also qualitative methods should examine this further. Furthermore, first aid courses may also contribute to the early promotion of general health literacy in primary school children (Böttiger & Van Aken, 2015; Beck et al., 2016; Bitzer & Sørensen, 2018).

The strengths of our study include its large sample spanning across 6 years of primary school age, including students from 6–13 years, and comprehensive assessments of their pre-/post-intervention attitudes, knowledge, and practical skills related to not only CPR but also general first aid.

Several limitations must be noted regarding our study. Firstly, we did not include primary schools from cities and more urban populations. Since we conducted our study in rural regions and small towns in the large territorial state of Brandenburg, our results may be considered representative only for the regions where the study took place and perhaps other non-urban areas in North-Eastern Germany, but not for the whole country. Secondly, we did not have a comparison group in terms of control schools. However, we used the students themselves as a control group, by comparing before-and-after assessments of knowledge and attitudes with identical standardized questions. Thus, we cannot fully exclude possible influences before and during the 2-day course including first aid techniques appearing on TV/internet, through parental interaction, or elsewhere in the community. However, during the short time period of 2 days, we consider this as a marginal influence.

Thirdly, we conducted the whole project with our own means and had no external funding, thus lacking resources to hire a single evaluator for the assessment of practical skills in all schools. Instead, we relied on a core team of experienced volunteer instructors, who have been specially trained and used the standardized evaluation form with subjective rating scales for each exercise to minimize measurement bias. We cannot exclude a potential evaluator’s effect but found no indication for it when looking at the school-specific results, which did not differ considerably among the schools (data not shown). Fourthly, from our study only using instructors with a medical background, we cannot draw conclusions about the effects of teachers training primary school students in first aid. However, there is evidence that teachers perform just as well as or even better in teaching first aid in schools than medical professionals (Bohn et al., 2012).

Our study showed that primary school students of all ages benefit from a 2-day first aid course. Especially those aged 8–13 years were able to improve their knowledge as well as their practical first aid skills demonstrating successfully the recovery position and application of compression bandages on fellow students, as well as resuscitation procedures on manikins. The youngest students, aged 6–7 years, also improved their first aid knowledge but to a lesser extent than their older peers.

Compared to the current recommendations to start resuscitation training in German schools at grade 7 (corresponding to age 12–13 years) our results clearly showed that such training will also be very beneficial for students younger than 12 years.

Previous recommendations already pointed out the importance of refresher training for children and young teenagers (Bánfai et al., 2019). Future evaluations are needed to examine the long-term benefit of first aid courses in primary schools and at what time refresher courses are required. We aim to conduct a follow-up after 2 years in the participating schools of the present study evaluating how sustainable their acquired knowledge and skills will be.

Future studies on children under 8 years of age should consider including teachers and pedagogic scientists to develop better age-specific programs for students aged 6–7 years. Future age-specific research should also focus on children’s attitudes and their willingness to help in an emergency (e.g., using mixed-methods approaches).

From a public health perspective, long-term and broad-scale population-based assessments are required to examine if school-based first aid courses will lead to more knowledgeable and self-confident adult by-standers (by both the students themselves and their parents through multiplier effects) and may eventually increase the number of bystander CPR.