Out-of-hospital cardiac arrest (OHCA) remains a major cause of mortality worldwide, with survival critically dependent on early recognition, prompt initiation of cardiopulmonary resuscitation (CPR), and rapid use of an automated external defibrillator (AED). Despite sustained public health initiatives, recent epidemiological data indicate that bystander CPR and AED deployment remain suboptimal in many regions, particularly in rural or geographically dispersed populations [1]. In Europe, OHCA represents a substantial public health burden, with an estimated annual incidence ranging from 53 cases per 100,000 inhabitants in Austria to 166 per 100,000 in Bosnia and Herzegovina [2].

Although advances in prehospital and emergency care have improved outcomes, overall survival remains limited. The EuReCa TWO registry, encompassing resuscitation attempts in 28 European countries, reported survival to hospital discharge in only 8% of patients [2].

In Spain, national registry data from 2022 documented an OHCA incidence of 24.2 cases per 100,000 inhabitants, with marked regional variation, with Catalonia reporting one of the highest incidence rates at 35.2 cases per 100,000. Overall survival to hospital discharge was 11.5%. These outcomes remain strongly associated with the timeliness and quality of bystander intervention, particularly CPR provision and AED accessibility. The “chain of survival”—early recognition, timely bystander CPR, rapid defibrillation, advanced life support, and postresuscitation care—continues to be central to improving OHCA outcomes [3].

Each minute of delay in chest compressions reduces survival by approximately 10%, whereas defibrillation within 3 to 5 minutes for shockable rhythms may increase survival to as much as 30% [4]. However, bystander CPR rates vary widely, from 26% in some regions to approximately 69% in communities with comprehensive public training programs.

Rural populations face distinct barriers to emergency response education, including limited access to certified instructors, long travel distances to training sites, and fewer opportunities for refresher courses [5]. These structural constraints likely contribute to lower CPR training rates and reduced AED awareness compared with urban communities, potentially widening disparities in OHCA outcomes [1]. In such settings, early intervention often depends on lay bystanders before the arrival of emergency medical services (EMS) [6-8].

Hands-only CPR has been demonstrated to be as effective as conventional CPR for most adult cardiac arrests, lowering barriers for lay responders and facilitating dissemination through community-based programs [6]. Nonetheless, substantial inequities persist between urban and rural areas. In rural contexts, EMS response times frequently exceed 10 to 15 minutes, AED availability is limited, and community CPR training coverage is lower. These challenges are often compounded by socioeconomic disadvantage, with underserved populations less likely to receive bystander CPR or early defibrillation [6].

Disparities in early resuscitation are particularly concerning in pediatric OHCA, where rapid intervention is essential. Globally, the annual incidence among children younger than 12 years ranges from 8 to 20 cases per 100,000 [9]. However, most schoolteachers report insufficient CPR training and limited confidence in performing or teaching resuscitation techniques. Although hands-only CPR is generally preferred by educators, overall preparedness remains inadequate [10].

Therefore, training schoolteachers in CPR may have a multiplier effect, enabling them to respond effectively in school environments while simultaneously transmitting life-saving skills to students and fostering a broader culture of preparedness within the community [11]. This approach is especially relevant in rural regions, where access to EMS is constrained and scalable digital solutions—such as online CPR courses—may represent practical and cost-effective alternatives.

Although traditional face-to-face CPR-AED training has proven effective, the COVID-19 pandemic accelerated the adoption of digital health education modalities, including blended and fully online programs. Emerging evidence suggests that online or hybrid CPR instruction combined with simulation-based practice can improve short-term knowledge retention and psychomotor skills, although findings remain heterogeneous and dependent on instructional design, learner characteristics, and assessment strategies [12].

Simulation-based assessment is increasingly used to evaluate CPR competence in standardized environments, enabling objective measurement of procedural accuracy, timing, and checklist-based performance [12,13]. However, improvements observed in simulated contexts should be interpreted cautiously, as such performance may not fully translate to real-world behavior during actual emergencies.

Despite growing interest in remote and community-based CPR education, evidence specifically examining online CPR-AED training for rural lay populations remains limited [1]. Most studies have focused on urban cohorts, health science students, or workplace settings, leaving an important knowledge gap regarding the feasibility and potential impact of digital training strategies in geographically isolated communities [13].

To address this gap, this study evaluates changes in theoretical knowledge and simulated CPR-AED performance among rural community participants before and after completion of an online training program supplemented by in-person simulation practice. Given the quasi-experimental pre-post design and the absence of a concurrent control group, the analysis focuses on observed improvements rather than causal inference.

This community-based study evaluated changes in theoretical knowledge and simulated CPR-AED performance following completion of an online training program supplemented with in-person simulation among lay participants—primarily primary and secondary schoolteachers—from rural areas in southern Catalonia.

Consistent with the study objectives, participants demonstrated significant improvements in posttraining knowledge scores and simulation performance compared with baseline. These findings suggest that a digitally delivered CPR-AED curriculum, when paired with structured hands-on practice, may enhance preparedness among non–health care professionals in geographically dispersed settings.

Out of the 55 individuals initially recruited, 52 completed the posttraining evaluation. Median knowledge scores increased from 6.72 (IQR 6-8.57) to 7.77 (IQR 7-8.67 out of 10), and participants required fewer attempts to complete the theoretical assessment, suggesting improved mastery of key resuscitation concepts. In addition, the improvement observed between the 2 simulated scenarios indicates retention of procedural skills, which is particularly relevant given that simulation assessments focused on core elements of basic life support and AED use. Although participants could repeat the test, the observed reductions in errors and increased procedural accuracy may reflect learning through feedback and iterative practice.

Unlike many community courses that focus solely on hands-only CPR, this program provided comprehensive basic life support training, including AED deployment. The online format offered logistical advantages and the potential to reach a broad audience, particularly in rural areas where access to face-to-face instruction is often limited.

All simulations were conducted individually at the participants’ workplaces using manikins and standardized cardiac arrest scenarios under supervision by certified instructors and observers, following the Catalan Council of Resuscitation guidelines derived from the ERC. The observed gains are consistent with prior studies demonstrating the feasibility and educational value of virtual or blended CPR instruction for lay populations [18-20].

However, the characteristics of the study sample warrant cautious interpretation. Approximately 70% of participants were women, 60% held a university degree, and approximately 30% resided in urban areas while working in rural schools. These demographic features may limit generalizability to the broader rural population and suggest that participants may have been more motivated or educationally advantaged than the general community.

Several limitations should be considered. First, the quasi-experimental pre-post design without a control group precludes causal inference regarding the effectiveness of the intervention. Second, although simulation-based assessments provide standardized and objective measures of performance, they may not fully reflect behavior during real-life cardiac arrest events.

Technical barriers also affected implementation, as internet connectivity was inconsistent in some rural locations, potentially limiting access to the online materials. Additionally, some substitute teachers who participated in the first simulation were unable to complete follow-up assessments because they were no longer employed at the same schools, resulting in attrition between testing phases.

Finally, the demographic composition of the sample and partial inclusion of participants residing in urban settings restrict external validity and should be taken into account when extrapolating these findings to other rural contexts.

This study suggests that online CPR-AED training supplemented by workplace-based simulation may represent a scalable approach to improving resuscitation preparedness among laypeople in rural communities. Beyond immediate educational gains, such programs have the potential to strengthen community emergency response capacity by establishing local networks of trained individuals, particularly in school environments where teachers can serve both as first responders and multipliers of knowledge.

Participants’ recommendations to integrate CPR education into primary and secondary school curricula, provide regular refresher training, and improve community awareness of public-access AEDs align with international calls for school-based resuscitation education as a cornerstone of population-wide preparedness. Therefore, future public health strategies should consider incorporating accessible digital training platforms alongside broader AED deployment to reduce disparities in OHCA outcomes, particularly in underserved rural areas.

Further research using controlled designs, longer follow-up periods, and more representative rural samples is needed to determine whether observed improvements in knowledge and simulated performance translate into sustained behavioral change and improved real-world clinical outcomes.