One hundred seventy students participated from private and public schools and colleges. Of these, 148 were from private and 24 from public schools. Fifty teachers participated, of which 42 were from the private sector and eight from the public sector. Eighteen parents were interviewed.
Characteristics of study participants
Total Number (N)
Overall, four main sub-themes emerged have emerged, as shown in (Table 2).
Emergent Themes and Sub-Themes
Community Barriers in helping the injured victims
► Lack of knowledge and fears/anxieties
► Fear of Legal involvement
► Lack of empathy among community stakeholders
► Gender Bias
► Fear of hurting the patient by incorrect technique
Students as life savers
► Physical strength
► Confidence and competence
► Parental and family Permission/agreement
► Effect on student’s studies
Elements of Training program for the students
► Willingness for training
► Student’s age-group for training
► Type of trainers (Doctors or Teachers)
► Mode and Strategies for implementing training and opportunities
► Duration, ratio and language of trainer
Implementation of national-level lifesaving skills program
► Support from Government and Senior Leadership
► Integration into the curriculum
► Legal support and protection
► General public awareness and marketing
Theme 1: Community Barriers in helping the injured victims
Most participants shared the barriers, fears, and apprehensions due to which people do not come forward and help in emergencies. Five-main sub-themes emerged are: Lack of knowledge and fears/anxieties, fear of legal involvement, lack of empathy among community stakeholders, and gender Bias
Fear of hurting the patient by incorrect technique
Sub-Theme 1.1: Lack of knowledge and fears/anxieties
Lack of knowledge and awareness about what to do and how to provide help to the patient in case of an emergency was the most commonly cited barrier among participants. Participants said that they do not provide help in an emergency since they are unaware of any lifesaving techniques or strategies.
One of the students said
“CPR is done to help the patients. Like when someone has an abnormal heart beat so we punch here to make the heartbeat normal” (Participant 02, student FGD 06)
One of the parents said
“See I am a housewife. I don’t know how to do it. There is awareness issue. You will only apply if you have the knowledge”- (Parent IDI 06)
Some of them heard about CPR in the media or Facebook (FB) but no such experience in their personal life. They were unsure if the CPR technique would work.
“I have heard people blowing out in patients mouth to revive their lungs. But i don't know if it works”. (Parent IDI 05)
A teacher said
“We have heard this term but we do not have much knowledge about it” (Participant 01, Teachers FGD 03)
Sub-Theme 1.2: Fear of Legal involvement
Fear of involvement in a police case was the most commonly reported fear by the majority of the participants. People were afraid to get their names involved in legal matters. Most participants said they did not want to get involved in legal issues when their intention was just to help the victim. A student said
“If the police is going to be involved, they will include us in the investigation.”( Participant 03,Students FGD 07)
Fear of legal involvement was so overwhelming that even if the people wanted to help, they would not come forward, as they wanted to avoid getting involved in any of the legal issues.
“Actually, people here are afraid from law and enforcement agency. What if they put your name in first incident report (FIR)? These things in society fear people to help assist” – (Participant 05, Teacher FGD 01)
A parent said
“If god- forbid there is a major situation occur then people get scared of it that if anything goes wrong our law enforcement agencies will not support us.” – (Parent IDI 17)
Sub-Theme 1.3: Lack of empathy among community stakeholders
Participants said that now people have become self-centered if they witness an accident. So, if a situation arises, people do not consider the victim as one of their own. The students added that in such a situation where people witness an accident, they would instead take pictures selfies, make videos, and post them on social media rather than come forward and help the victims.
One of the students said
“People nowadays are more interested in making videos and then uploading it on social media to get famous” -( Participant 05, student FGD 08)
Participants also talked about fast passed life and time factor. They felt that the dilemma is that people are very busy in their lives and do not have time to help others. Therefore, they will not stop to check on the patient and continue their journey un-bothered since they are not related to the victim.
One of the teachers said
“People prioritise their time so that they think they will waste time getting caught up in the situation. Also, they at times cannot feel for that person (victim) suffering” -( Participant 03, Teachers FGD 06)
One of the parents said
“People are very selfish now a days. This is what I have noticed. They save themselves that why should we get involve with others. Selfishness” (Parent IDI 17)
Sub-Theme 1.4: Gender Bias
Some participants mentioned they would hesitate to help due to gender-based, cultural barriers. Women feel embarrassed to come forward and help if the victim is a male.
A student said
“If there is a girl and she knows what to do still she will not come forward because there are men in crowd”- (Student 02, FGD 07)
“Gender difference could be a barrier in performing CPR. Being of the opposite gender as that of the victim’s would be the barrier in this case” (Participant 02, Teacher FGD 01)
Another teacher added females will not get permission from their families to come forward in such a situation.
“Would they be comfortable with men performing CPR on women and vice-versa? Would they even allow females there to learn CPR? So there will be many challenges. “ (Participant 05, Teacher FGD 03)
A parent said, that there would be hesitation in helping the opposite gender. However, he did acknowledge that this is not an issue in the western world.
“See gender bias is the first thing. If a man is dying, a woman cannot help him and when a woman is dying man is scared to approach. Abroad I have seen people helping each other.”- (Parent IDI 11)
“Being a woman, yes, I would be careful moving through a crowd”- (Parent IDI 09)
Sub-Theme 1.5: Fear of hurting the patient by incorrect technique
Many participants expressed fear that they will hurt the patient if they perform CPR in real life. In addition, people expressed their reluctance to cause damage to the patient by either pushing too hard or performing it in the wrong way.
A student believed that
“For CPR I have heard you need to press on the chest and that could make some problem in the person’s cardiac issues and you could also hurt them”- (Participant 07, Student FGD 08)
One of the teachers shared her concern that she is really unsure about how to perform the procedure correctly. She felt that this might hurt the victim as she didn’t know how to correctly attempt the CPR.
“We don’t know the right time and place. Maybe we do wrong instead of doing it correctly. What if I pressed more hardly?” (Participant 02, Teachers FGD 04). The participant looked concerned while expressing her uncertainty.
One of the parents said
“I think lot of people have, umm, fear of something going wrong. I know, like I have fear of pushing too hard and breaking the ribs ” -(Parent IDI 06)
Theme 2: Students as lifesavers
The participants shared their views, opinions, and concerns regarding training students as lifesavers. The four main sub-themes that emerged are: physical strength, confidence and competence, parental and family permission/agreement, and effect on student’s studies.
Sub-Theme 2.1: Physical Strength
Most participants believed gender and physical strength were not obstacles to learning and performing CPR. Most participants said the students especially female students had good physical strength to perform such skills. A student explained the physical strength of women by comparing it with childbirth.
“If a woman can tolerate the pain of breakage of 21 bones when giving birth, her physical strength is more than the others. If she can bear this, she can do anything”- (Participant 05, Student FGD 05)
A teacher said
“I think children in middle school and above are physically fit enough to do this” (Participant 3, Teacher FGD 4)
A parent had the same confidence in his daughter's skills as his son. He said, “I don’t think my daughter lacks physical strength” (Participant 01, Student FGD 10)
Sub-Theme 2.2: Confidence and competence
Parents and students felt a lack of confidence could hold back the children. The children might lack confidence initially, but with time, training and experience they will gain the confidence to perform these skills. Some students also felt less confident. They attributed it to; lack of adequate knowledge, not performing correctly and making mistakes, and fear of hurting people. Few students’ perspectives were
“I can make mistake” -( Participant 02, Student FGD 03)
“I don’t want to take risk”- (Participant 05, Student FGD01)
“I am not sure about performing it on someone else”-(Participant 04, Student FGD 05)
A Parent said
“Probably not the first time. But after that she will be confident and knowledgeable about the actual process” -(Parent IDI 5)
Sub-Theme 2.3: Parental and family permission/agreement
Few teachers shared their concerns that the children will not be given the responsibility in the presence of older family members. A teacher said
“My concern is that it is impractical for the children because even something happens at home, No one at home will allow children to do.” (Participant 05, Teachers FGD 07)
Most parents were encouraging and said they would allow their children to save someone's life if they got the opportunity. They would feel happy and proud if their child can save someone's life
“I think I would allow my child to do that, in fact I would appreciate it if my child could be of help to someone.” (Parent IDI 16)
“Life and death are in the hands of Allah but if he can help to save lives like doctors it is his responsibility to help people.” (Parent IDI 14)
However, few parents felt uncomfortable in permitting their children to take charge in such situations. A mother was worried about her child being only son and said her child would need permission from the father.
“This is something his father can tell because I only have one son” (Parent IDI 06)
“He cannot go far. If something happens in our neighbourhood, then he can help" (Parent IDI 15)
Sub-Theme 2.4: Effect on student’s studies
Some participants shared their concerns that the children's studies might get affected. They provided justifications that, the children were already overwhelmed with such busy timetables, upcoming exams, and introducing such training might hinder their academics. Some of the students felt uncomfortable due to the heavy academic load. They suggested conducting the training in free periods so that their studies are not compromised. A student said
“Ma’am if you give us training in one period that is fine but if you want us to study more about it, then we have our own studies and they will get affected.” (Participant 06, Student FGD 09)
A parent said
“My son is in matric and the education load on them is way too much. They have their exams coming up it will be difficult for them to manage” (Parent IDI 05)
Theme 3: Elements of Training program for the students
All participants supported training students with lifesaving skills in schools in Pakistan. They talked about the inter-related components needed for training students with lifesaving skills in schools. Six main sub-themes are: Willingness for training, students age group for training, type of trainers (Doctors or Teachers), mode and strategies for implementing training and opportunities, duration, ratio and language of trainer.
Sub-Theme 3.1: Willingness for training
Almost all the participants had a positive attitude and showed a willingness to train for lifesaving skills and felts everyone should know these skills. They supported imparting lifesaving skills to students in the schools. They suggested that it would be suitable to train those on the fore-front, i.e., students, teachers, administrative staff in schools, police officers, and working force. Almost all the parents felt that it was good to equip children with these skills since anyone can face an emergency.
A student said
“Everyone should know that in case of emergency when an ambulance is on the way, what they can do to help” (Participant 04, Students FGD 16)
A teacher shared her thoughts
“It will help them a lot that they will know what to do when there is an accident, what and how to do.” (Participant 02, Teachers FGD 06)
Few parents shared
“I think traffic police is very important on roads. Similarly, in institutes teachers and staff are main people, train them also” -(Parents IDI 10)
“It should be taught and children should know how to perform CPR. Children should be able to deal with these situations. Moreover, in situations like these, it is very difficult to find a doctor so children should be enabled to perform CPR”. (Parent IDI 05)
Sub-Theme 3.2: Student’s age-group for training
Most participants suggested that this training should begin early on in life. The parents suggested it was suitable, to begin with training students in grade 9th and above in terms of age group.
“ At least 13 years of age”- (Participant 5, Student FGD 09)
Teachers also suggested to train the secondary school's children.
“We should start from secondary classes, because this is when a child begins to understand complex concepts like these. What is taught early in life usually remains with the person forever.” (Teachers FGD 1)
Parents shared their thoughts
“Girls and boys of class 9th, matric and also inter should be taught” (Parent IDI 03)
“The kid has to be mature that I can’t really specify an age. Over 15 would be good, I think". (Parent IDI 11)
Sub-Theme 3.3: Type of trainers (Doctors or Teachers)
Most of the participants trusted doctors or medical professionals as better trainers, since they were the subject experts. Students had a mix-response; some were comfortable learning from the doctors, while some supported their teachers in this regard.
“We are not comfortable with anyone other than doctors.” (Participant 2, Students FGD 4)
“This will be best. They (teachers) already teach us so we will be able to learn theory and practical combined in this way.” ( Participant 4, Students FGD 9)
Most teachers supported training teachers to learn lifesaving skills, but there was a strong opposition for curriculum teachers as trainers. They felt that if this training program was to be implemented, then only newly hired teachers, physical education teachers, science/biology teachers should conduct this training for the students in the schools. They suggested recruiting new teachers designated explicitly for these training, increasing the number of Physical Education (PE) teachers so that the curriculum teachers are not burdened with this additional work.
“Sports teachers should be trained; the number of sports teachers should be increased so that the knowledge can be delivered to students better. The curriculum teachers are already occupied with exam preparation, syllabus completion, and result making, amongst other things. I do not think burdening these teachers with this extra task would be a good decision”. (Participant 2, Teacher, FGD 1)
“We should have designated teachers for this course, as curriculum teachers already have plenty on their plates. While curriculum teachers should also be taught these skills, separate, qualified instructors should be hired for the job of educating the students.”- (Participant 3, Teachers FGD 1)
“The PE teachers are also separate from curriculum teachers. This responsibility should not fall on the shoulders of curriculum teachers”- (Participant 4, Teacher’s FGD 1)
Some teachers suggested that science teachers would be the appropriate choice amongst the curriculum teachers.
“Those who already have a science-based degree such as medicine, biochemistry, or biology, would be better suited to teach this content”- (Participant1, Teacher FGD 04)
“I think science or biology teachers can give proper awareness as they know better about human body as compared to me. I am an accounts teacher. They can better function and structure the training because they have more awareness of body parts as they teach about it.” (Participant 2, Teacher FGD 04).
The trust in teachers as trainers was low for most of the parents.
“Do you think that we have that kind of teachers available who are capable of teaching children CPR effectively. The doctors should make teams and then train the children”- (Parents IDI 15)
“Doctors should teach them. Teachers’ job is to teach. I think students will learn better from doctors. I think students will trust and learn more from the doctors” -(Parents IDI 8)
Sub-Theme 3.4: Mode and Strategies for implementing training and opportunities
Almost all the participants suggested conducting one-on-one, face-to-face sessions for these training. They felt lectures were appropriate for teaching the theory, and practical/hands-on drills were suitable for the skills session.
Students shared their thoughts
“In-person would be the best way because online lectures are boring. We can show proper demonstrations in the in-person sessions as well.”- (Participant 3, Students FGD 9)
“Give everyone a chance to practice on mannequins”-(Participant 2, Students FGD 8)
Teachers said that not all students have access to the internet and smartphones. Teachers were worried that a large chunk of students, especially those in rural areas/low-socio-economic strata, would be left out in case of online teaching due to lack of resources (electricity, internet, smartphones)
“Online access appears to be the biggest problem, as in a class of more than 20, hardly 5 have access to the internet. Many of the students will miss out if these sessions are conducted online”- (Participant 5, Teacher FGD 03)-The teacher looked worried while he expressed his thoughts.
“We teach rural schools and our students do not have the resources. Only 2 or 3 students in a class have cell phones or other handheld devices. These are kids who at times cannot even afford school fees. Sir this will not work, it is not a valid option for our schools. Here in our areas, the only option seems to be that the teachers themselves conduct in-person sessions”. (Participant 2, Teachers FGD 03)
Parents also favoured face to face teaching
“Online is not good. Most of the children do not have WhatsApp. It is very difficult.” – (Parent IDI 18)
Most teachers felt that videos were a good resource for delivering the training. However, they suggested using brochures and pamphlets in those areas that lacked the resources to play videos in schools and larger communities.
“I believe we understand information delivered via video much better than that delivered via pamphlet. Visual learning is much more effective”- (Participant 3, Teachers FGD 1)
“Videos for the schools and brochures/pamphlets for the community.”- (Participant 4, Teachers FGD 3)
Sub-Theme 3.5: Duration, ratio and language of trainer
There was a varied response regarding the duration of the training sessions. However, most participants suggested having small sessions spread over months. They suggested having thirty to sixty minutes long, weekly sessions/classes. The teachers felt shorter classes would keep the students engaged and interested.
“I think it should be given over many weekly sessions for several months. The duration should be short to maintain interest, and make sure that it is not treated as a burden”- (Participant 2, Teacher FGD 1)
“I think 2 classes a week are a must. They should be one hour long”- (Participant 3, Teacher, FGD 2)
“Each class should be thirty to forty minutes long”- (Participant 4, Teacher, FGD 1 )
Teachers and students felt there should be frequent refresher training. These could be annual or bi-annual and should have some new and additional knowledge.
“There should be additional knowledge in refresher trainings”- (Participant 3, Students FGD 5)
“There should be annual refreshers”- (Participant 5, Teachers FGD3)
“The refreshers should be conducted every six months”- (Participant 4, Teachers FGD6)
The teachers suggested conducting the training in small group sessions. An ideal situation would be five to ten students per trainer. This would enable a good learning environment, and things would be easier for both the participants and instructors.
“1 instructor for every 5 students would be ideal. A small group would create a better learning environment, especially during the practical component as the instructor would be more comfortable delivering knowledge to a smaller audience and the students will also be more excited to learn/work with more individual attention.” -( Participant 4, Teachers FGD 1)
“I would suggest a maximum of 10 students per instructor as a smaller group would make matters easier for both students and the instructor” (Participant1, Teachers FGD 1)
Most participants suggested using Urdu (National Language) as a mode of instruction. Alternatively, at least it should be bi-lingual in English and Urdu. However, the teachers and students both suggested use of regional languages would be better for rural areas
“This would depend on the school because English will not be the best decision for many schools. The mother tongue works best, and where English is not working, we can go with Urdu”- (Participant 3, Student FGD 6)
Theme 4: Implementation of national-level lifesaving skills programs
The participants suggested focusing on several action areas if we want to implement an impactful national-level program. All these elements are essential to ensure the successful implementation sustainability of the program. The four sub-themes emerging are: Support from government and senior leadership, integration into the curriculum, legal support and protection, and general public awareness and marketing
Sub-Theme 4.1: Support from government and senior leadership
Most of the participants felt governmental support was needed to ensure every student gets an opportunity to learn lifesaving skills.
The teachers highlighted a critical issue of socio-economic disparities. They felt learning lifesaving skills was a significant investment, and the government should fund it so that we do not leave any students behind. However, some teachers highlighted the financial constraints for training in all schools.
“The government will have to support the campaign by subsidising these things, else this cannot occur on the large scale”- (Participant 4, Teachers FGD 1)
“We may face potential constraints of financial resources. This would be as only a few schools/students would take interest in a paid course, whereas a free-of-cost course could be difficult to set up.” (Participant 3, Teachers FGD 2)
A parent shared
The provincial health department should be responsible for this. And the financial part should also be the responsibility of the government.” – (Parents IDI 13)
Sub-Theme 4.2: Integration into the curriculum
Most participants felt the lifesaving skills training should be made part of the school and college curriculum. They said it should be made part of the curriculum.
“Schools prepare us for academic life but something like this will prepare us for the life we have ahead of us and god forbid if any tragedy happens, we can prevent it -it should be part of our curriculum”- (Participant 2, Student FGD 3)
Teachers suggested that instead of keeping it as a one-off activity/course, it should be integrated into the curriculum. It should be mandatory training for all the students.
“This will definitely have to be part of the curriculum, as only a stand-alone workshop or a series would not be adequate enough to develop the required level of understanding.”- (Participant 4, Teachers FGD 1)
Further, the teachers suggested a chapter may be added in the science subjects.
“In the book of science, a portion can be added related to the first aid.” (Participant 1, Teachers FGD 06)
When she was a student, one of the teachers recalled that they had basic life support training as part of her school's Physical Education (PE) and recommended a similar course of action.
“I would like to add that when I was in school, basic life support was part of our curriculum. I would suggest similar action, where we introduce this as part of the PE syllabus”. (Participant 5, Teachers FGD 1)
Sub-Theme 4.3: Legal support and protection
Participants talked about changing the legal environment. For example, if the public knew that they would not get legally involved if they helped someone in an emergency, the situation would surely change.
“We assure them if they even mess up, it is in good faith. They are not responsible”- (Participant 3, Students FGD 6)
“A campaign should be done on media so the fear of police from hearts can go. Police will not say anything; we will not get involved in any case” (Participant 4, Teachers FGD 05)
“There's also fear of getting into legal issues and getting involved with police. It won't happen overnight, but as I mentioned earlier awareness campaigns will help. And people would know that they won't get harassed for trying to help out”- (Parent IDI 12)
Sub-Theme 4.4: General public awareness and marketing
All the participants talked about creating awareness amongst the general public that bystanders can save lives in an emergency. The communities need to be aware that lives can be saved before professional help arrives. Therefore, it is vital to get acceptance by the general public. Different strategies were suggested to get penetration into the communities. This includes; the use of tv shows and advertisements, social media, marketing to create awareness among the masses. Students discussed using the famous morning tv shows and engaging famous personalities such as social media Influencers to reach out to the general public.
“Engage Social Media Influencers”- (Participant 6, Students FGD 07)
“Teach CPR and bleeding control on morning shows”- (Participant 7, Students FGD 05)
Teachers shared their thoughts
“Use sign boards to provide awareness about first aid. You can see social responsibilities on the road. Or upload on social media”- (Participant 5, Teachers FGD 02)
“I think television could be used to provide awareness to the masses first, and then we can have sessions so that people can understand the practical aspect”- (Participant 3, Teachers FGD 1)