Quality Learning in Basic Life Support in Portuguese Basic Education School: A Cross-Sectional Study with 10th Grade Students
Round 1
Reviewer 1 Report
Dear Authors
This study aimed to identify the theoretical and practical knowledge and self-reported skills in Basic Life Support (BSL), in order to characterise the motivation to intervene in an emergency situation. Authors found that students have weaknesses in theoretical and practical knowledge in the field of BLS but motivation to intervene is high since students are sensitive to the topic.
The manuscript addresses a relevant problem. The topic addressed in the manuscript treats an important concern in public health. Abstract includes introductory statement that outlines the background and significance of the study. Introduction summarizes relevant research to provide context and clearly state the problem. The topics are well developed and confronted to other publications. The research methods used ensure the reliability of the obtained results. The term “cross-sectional study” must appear in the title of the manuscript in accordance with the guidelines for cross-sectional studies.
The results are presented clearly. The figures and tables have clear structure. The discussion section interprets the findings in view of the results obtained in this and in past studies on this topic. The conclusion must be succinct and related to the study. Part of the conclusion could be integrated into the discussion, perhaps a point on future perspectives.References cited are recent and have a high relevance to the problem.
Author Response
Dear reviewer
I begin by thanking you for your interest and contribution to improving our work. We send below, highlighted in green, our proposals in view of your suggestions.
Academic greetings
Authors
Author Response File: 
Author Response.pdf
Reviewer 2 Report
The article addresses an extremely interesting and little-studied topic. In the Portuguese context, these aspects are even more relevant, which reinforces the pertinence of the study. The introduction is clear and covers all the necessary aspects. However, the methodology and the results are not always clear and there are some fundamental issues that need to be clarified.
For example, in the component related to students' knowledge, they were asked to indicate whether they agreed with 57 statements. Among the 57 statements some were false, and some were true. Therefore, more than indicating whether the students agree or disagree with the statement, it is important to see whether they answered correctly or not. I think that the analysis in this way would be much clearer for the reader. Also, I have a lot of questions about some of the statistical measures used. For example, indicating that the modal value is “agree” does not seem to be informative. Again, the analysis would depend on the nature (true or false) of the statements. Furthermore, in the case of a dichotomous variable, what is the pertinence of the standard deviation?
So, the study has a huge potential, but it is necessary to improve the results, otherwise the publication of the study is not deemed appropriate. Moreover, the paper is not written in sound English, so it is important to improve the writing during the revision process.
Below I present a list of aspects that I believe need further reflection and reformulation.
Methods
- line 72 – “representative sample of students from the 10th grade” – how was this done? More information should be added.
- line 92 – “after the pilot testing process, formed a group 92 of 57 items”. Then, in line 106 there is a comment regarding “the judges' opinion”. Only in line 118 the pilot is explained in more detail. I believe you should organize the information in a clearer way.
- Table 1 – “1. CoS and survival rate in OHCA” – number of false items should be 2 and not 3.
- Table 1 – “2.5. Circulation checks” – why ask things about this topic? The algorithm does not include circulation checks.
- Table 1 – improve the table formatting. For example, is not easy to understand that some items are sub-indicators.
- Why a table only for dimension 2? More tables and graphs would help visualizing the results.
- line 84-87 – why perceptions for D3, D4 and D5 and conceptions for D6?
- line 97-104 – I have many doubts regarding the scales used. In the first questions of D3 and D4 there are five categories: 1) “the topic has not been addressed”, 2) “I do not feel prepared”, 3) “I feel underprepared”, 4) “I feel well prepared”, 5) “I feel very well prepared”. To conclude D3 and D4, students should evaluate using a 10-point scale as a reference matrix [from 1 ("very weak") to 10 ("excellent")].
So, it seems that the rational was not always the same. Why is the category “the topic has not been addressed” present in the first questions, but not in the last one? Moreover, students knew that they were answering about aspects regarding 9th grade? In the questionnaire there is no reference regarding this aspect.
- line 106 a 109 - Once again, in D5 the categories are not in the same line, since only four response categories were developed. According to the text in line 108-109 the four categories are: “1) “I do not feel prepared”, 2) “I feel underprepared”, 3) “I feel well prepared”, 4) “I feel very well prepared”. However, in the questionnaire, in part V – Perceptions on skills acquisition – the categories are: The topic was not ad-dressed; I don't feel pre-pared; I feel un-pre-pared; I feel well pre-pared.
- Line 130 – “For data treatment, the answers were scored, with the highest value being agreement with the theoretical framework / I feel very well prepared.” – more information regarding the use of this score is needed. This is quite important to understand the results presented.
Results
- line 150/154
“3.2. Perceptions on the appropriation of theoretical and practical knowledge in BLS
3.2.1. CoS and the survival rate in OHCA
The results show that about 75.0% of the students have the appropriate theoretical knowledge about the CoS and survival rate in OHCA, results that agree with those found in other authors”
It seems that the titles are not coherent with the text content … appropriate theoretical knowledge (D2) is not the same as perceptions on the appropriation of the theoretical knowledge. I believe the 3.2. title should be changed.
- line 152-166
“The results show that about 75.0% of the students have the appropriate theoretical knowledge about the CoS and survival rate in OHCA, results that agree with those found in other authors.
The modal value of this indicator is two, corresponding to the agreement with the propositions presented. The statement with the highest consensus (93.3%) is about the purpose of BLS performed by the bystander (q2 - "The purpose of BLS, performed by the person who witnessed an OHCA, is to maintain breathing and circulation until differentiated help arrives"). The false propositions (q1 - "BLS corresponds to any form of chest compression or artificial ventilation" and q5 – “The links in the CoS are sequentially: Early BLS (resuscitation); Early access to Emergency Medical Services (call 112); Early defibrillation (to restart the heart); Early post resuscitation care (to restore quality of life)”) are those that generated the greatest dispersion of responses, with SD, respectively, of .493 and .498. Even so, the majority disagree with the positions (respectively, 55.0% and 58.3%), aligned with the theoretical framework. The female students show less correct knowledge than the male students, in a difference of one percentage point, without significant expression (p = .269).”
What do you mean by “75% of the students have the appropriate theoretical knowledge about the CoS”? How was this % calculated? For this indicator the questionnaire has 3 items that are true and 2 that are false. The paper also says that only 55% of the students answered correctly the item q1.
“The modal value of this indicator is two, corresponding to the agreement with the propositions presented.” – why the modal value is two? We are talking about a dichotomic variable (agree or disagree; correct or incorrect). Moreover, there are 3 items that are true and 2 that are false… So, this kind of analysis is not coherent.
“The female students show less correct knowledge than the male students, in a difference of one percentage point, without significant expression (p = .269)” – the p-value should not be the only result to be reported; the test result should be reported.
- Line 176-177 – “This maximum value is only exceeded in item q14 ("A victim who reacts to the assessment of the state of consciousness should be kept in the position he/she was in"), with a 5.3:4.7 split between agreement and disagreement.
What is 5.3:4.7?
- Line 181- 182 – “The expression that generated the highest acceptance refers to the need for the bystander, before approaching a victim, to ensure safety conditions for him/herself, the victim and third parties (q6 – 92.3%).”
This information is repeated (see line 169-170).
- Line 203 – “Knowledge about airway permeabilization is confided by about ¾ of the students”.
What do you mean by “confided”?
- Line 219 – “they should act as if res-breathing is present, contrary to the literature”
What do you mean by “res-breathing”?
- Line 238-239 – “According to the results, the requirements for applying the lateral safety position 238 (LSP) are the domain of 68.8% of the students.”
It is important to improve the translation…
- Line 254 - “Three items were selected by more than 87.0%,”
What do you mean by selected?
- Line 258 – “ever, as to when to activate the European emergency number. whereas almost half”.
The punctuation needs to be corrected.
- Line 261 – “40.0% in another control question”.
I believe this is the first time you mentioned the concept of control question.
- Line 338/339 – “Still, about 47.3% of the assertions received ≥ 75% favourable points. Seven propositions registered agreement values ≤ 50.0% and two were even ≤ 25.0%.”
What do you mean by “favourable points”?
- Line 348-351 - “The analysis of the information reveals that 22.9% of the respondents declare that they are not prepared, in theoretical terms, on the themes of the BLS, either because the themes have not been approached (7.7%), or because, despite having been approached, they do not feel effectively prepared (15.2%).”
Once again, it is necessary to explain how the percentage was calculated… For dimension 3 – perception about theoretical training - students had to evaluate different items…
- Line 360 – “Regarding the lack of preparation, 38.8% do not know how to provide help for severe airway obstruction in infants”
Results should be written with more rigor. In fact, we cannot say 38.8% do not know how to provide; only that 38.8% reported not knowing.
- paragraph line 364/369 and 370/377 – repeated and confused information. For example, it doesn’t make the way the scales are formed: “a) “reasonably prepared" being the agglutination of the perceptions "poorly prepared" and "well prepared”; b) “well prepared", the combination of the perceptions "well prepared" and "very well prepared".
- Line 409/410 – “This is followed, above 50.0%, by practical training on assessment of respiration signs (q77), with 54.1% of choices, and on chest compressions in adults (q81), with 50.1%. All other subjects are below the average line in terms of preparedness.”
What do you mean by choices and average line in terms of preparedness?
- Line 474 – “The results associated to the variable "gender" reveal that the students who answered the questionnaire feel better prepared (5.1%) than the girls.”
There is something missing in the sentence.
- Line 495 – “Students were asked to name one constraint that prevented them from intervening in the community in a real emergency”
In the past? Or in the future?
- Line 498 – “The fact that the victim is a relative does not prevent that it was the choice of only 8.8% of the respondents. Some of these barriers coincide with others already identified [31], such as the particular cases of the victim being a family member.”
It is not clear what you mean. Contradictory ideas in the two sentences.
- Table 2 – Once again, it is important to report the test result and not only the p value, otherwise it is not possible to evaluate the level of association.
Conclusion
- Line 561 – “It can thus be inferred that the teaching and learning of BLS in schools, in Portugal, is far from what is defined in the Essential Learning for 9th grade, in the subject of Natural Sciences [23]”
But this was not made clear in the literature review section.
Author Response
Dear reviewer
I begin by thanking you for your interest and contribution to improving our work. We send below, highlighted in green, our proposals in view of your suggestions.
Academic greetings
Authors
Author Response File: Author Response.pdf
Round 2
Reviewer 2 Report
New revision
The revision didn’t improve enough the results and, therefore, I believe the publication of the study is not deemed appropriate. To justify my position, I will give a list of some examples of aspects not properly addressed by the authors. However, the list is not exhaustive, since more examples could be added.
I still believe that the study has a huge potential, but it is necessary to improve the results and to review the document carefully and systematically. Moreover, extensive editing of english language is required.
Example 1
Initial reviewer comment
- Table 1 – “2.5. Circulation checks” – why ask things about this topic? The algorithm does not include circulation checks.
Authors answer
The pedriatic algorithm include circulation checks. Items 27, 28, 29 and 30 refer to pediatric patients.
New reviewer comment
In Portugal the INEM is the institution with responsibilities in basic life support training. According to this institution, there is no need to check for circulation (this procedure was abandoned). See the manual in the following address:
https://www.inem.pt/wp-content/uploads/2022/10/Manual-SBV-Ped-26Out22.pdf
Also consult the European Resuscitation Council Guidelines for Resuscitation
Example 2
Initial reviewer comment
“What do you mean by “75% of the students have the appropriate theoretical knowledge about the CoS”? How was this % calculated? For this indicator the questionnaire has 3 items that are true and 2 that are false. The paper also says that only 55% of the students answered correctly the item q1.”
Authors answer
The average of the results, according to the theoretical framework, corresponds to 75% (q1 – 55,0%, q2 – 93,3%, q3 – 85,2%, q4 – 83,2%, q5 – 58,3%). The paper also says that only 55% of the students answered correctly the item q1. And it is correct.
New reviewer comment
We only can say that I student has the appropriate knowledge if they answer correctly to all the 5 items regarding CoS. So, the % of students that have appropriate knowledge can never be 75% because only 55% of the students answered correctly to the item 1. The 75%, the value present in the paper, has a different meaning. This misinterpretation is present all over the results section.
Moreover, the fact that I can calculate interquartile range in the SPSS doesn’t mean that it makes sense to do it. This kind of calculation only is adequate when we are dealing with quantitative variables or qualitative ordinal. In this case the variable is qualitative nominal (correct/incorrect). Although the authors choose to code the students answers with 2 points when it is correct and 1 point when it is incorrect it does not change the type of variable. This is also true for standard deviation.
Example 3
Initial reviewer comment
“The female students show less correct knowledge than the male students, in a difference of one percentage point, without significant expression (p =.269)” – the p-value should not be the only result to be reported; the test result should be reported.
Authors answer
“The female students show less correct knowledge (74.6%) than the male students (75.6%), in a difference of one percentage point, without significant expression (p = .269).”
New reviewer comment
The test result is not the % of female or male students. Which test was used? Chi-squared? According to APA the test result should be reported. This aspect needs to be improved all over the results section.
Author Response
Dear Editor-in-Chief
We begin by thanking you for contacting us and for sending the second round of the opinion. On this subject, we elaborate the following considerations:
1 – The text was translated by an official translator, who presented credits to the research center that financed the translation. Since none of the authors of the work is a native English speaker, we do not have the conditions to validate the position that “extensive editing of English language is required”.
2 – In principle, we are always available to learn, in particular appreciating the comments and suggestions of reviewers, integrating them whenever possible. This is the basic principle of permeability for learning and scientific production.
3 – And that was precisely what we did with the comments of reviewer 1 and reviewer 2 about the work “Quality learning in basic life support in Portuguese basic education school: a cross-sectional study with 10th grade students”, including even changing the title initial. In the continuation of the first round, we introduced the changes, proposed by reviewer 1 and the overwhelming majority of the indications advanced by reviewer 2.
4 – There are, however, established limits, which we are not willing to exceed.
5 – The article originates from a doctoral thesis that was validated by a legally constituted jury, which unanimously approved it.
6 – Reviewer 2 systematically insists that “the publication of the study is not deemed appropriate”.
7 – Considers that the data analysis is not coherent. But not everything is as claimed.
8 - For example: when we defini a general objective / variable, abstract and of mental action, this can be assessed through specific objectives / descriptors, concrete and of observable action. It is through the achievement of specific objectives / descriptors (subjected to a weighting coefficient) that we conclude about the achievement of the general objective. Now, if the knowledge about the “chain of survival” indicator (abstract variable and of mental action) is assessable through five specific items (concrete and of observable action), it will be precisely through these five variables that we know the appropriation of knowledge about the “chain of survival” indicator.
When it is stated that 75% of students recognize the importance of the chain of survival, it is because the average of the knowledge demonstrated about the “chain of survival” (q1 – 55.0%, q2 – 93.3%, q3 – 85.2 %, q4 – 83.2%, q5 – 58.3%) (assigning a weighting coefficient of 1 to each item) is 75%. Considering the weighting coefficient of 50% (commonly used in the evaluation of students for approval), the 75% turns out to be a favorable and positive knowledge, even if only 55% of respondents disagree that “BLS corresponds to any form of chest compression or artificial ventilation” (q1). Because, it should be noted, the indicator is evaluated through 5 items and not each one individually.
To ignore this is to disregard basic valid knowledge that dates back to the second half of the 20th century. Affirming “the % of students that have appropriate knowledge can never be 75% because only 55% of the students answered correctly to item 1. The 75%, the value present in the paper, has a different meaning. This misinterpretation is present all over the results section” reveals the lack of knowledge about this process.
9 – But the case gets even worse, when least expected. Reviewer 2, in the first round, considered: “Table 1 – “2.5. Circulation checks” – why ask things about this topic? The algorithm does not include circulation checks”. We thought it was an oversight on the part of the reviewer and replied: “The pedriatic algorithm include circulation checks. Items 27, 28, 29 and 30 refer to pediatric patients”.
The case thickens when, in the second round, reviewer 2 comments: “In Portugal the INEM is the institution with responsibilities in basic life support training. According to this institution, there is no need to check for circulation (this procedure was abandoned). See the manual in the following address: https://www.inem.pt/wp-content/uploads/2022/10/Manual-SBV-Ped-26Out22.pdf. Also consult the European Resuscitation Council Guidelines for Resuscitation”.
In our work, it is stated without any doubt that the questionnaire was applied to a population of students in the 2019-2020 school year (lines 12, 84). Now, in 2019-2020, the manual that reviewer 2 indicates simply did not exist! Because it dates from October 2022.
In 2019-2020, INEM had the “Basic Pediatric Life Support Manual”, version 3.0 as a reference – 1st edition 2017. Underline: 2017!. And, in 2017, INEM states that, if you are well trained, you can try to palpate the central pulse while looking for other signs of life (in infants, you should palpate the brachial pulse, on the inside of the arm, and in children, the carotid pulse. In any case, of the groups can palpate the femoral pulse).
Students are not health professionals, and that is an accepted point. However, the investigation tried to find out if the search for signs of circulation was taught and this seems to us to be perfectly legitimate.
Finally, we considered the pediatric algorithm has some degree of complexity compared to the adult algorithm. And precisely for this reason, translating into a simplification in the new edition of October 2022. But to claim that a 2019-2020 study should have used the 2022 manual is simply surreal.
10 - All of this reveals, for us, it is understood, the excess of zeal and another intentionality in the appreciation of our work, which is serious and honest. We do not need “more examples could be added” precisely because we will not consider them!
11 - We do not want the prestigious journal Societies to be indexed to a work that, in the opinion of reviewer 2, “the publication of the study is not deemed appropriate”. Therefore, we took the decision to withdraw the work, leaving the reviewer more relaxed, despite the invitation from the editor Prof. Isilda Rodrigues Teixeira, from UTAD, Portugal.
I am sorry for the inconvenience caused.
Best Regards
Jorge Bonito
