Virtual reality versus theoretical training in CPR among adolescents: a randomized trial with a one-year longitudinal follow-up

ERCT Criteria Breakdown

• Level 1 Criteria

  • C

    Class-level RCT

    • Randomization was performed at the individual student level, not at the class (or higher) level, and the intervention was not a one-to-one tutoring intervention.
    • "The random assignment was performed individually, in a 1:1:1 ratio, through a sequence of random numbers generated by a computer (RAND function in Excel)."
    • Relevant Quotes: 1) "The random assignment was performed individually, in a 1:1:1 ratio, through a sequence of random numbers generated by a computer (RAND function in Excel)." 2) "Firstly, it was conducted in a single school, which benefitted the follow-up, but restricted the generalization of the findings to other contexts, levels of education, or regions." Detailed Analysis: Criterion C requires randomization at the class level (or stronger, such as school-level) to reduce contamination within classrooms, unless the intervention is explicitly one-to-one tutoring/personal teaching. The paper explicitly states that "random assignment was performed individually," and also indicates the study was "conducted in a single school." Individual (student-level) randomization in a single school implies that students who share classes/teachers can end up in different arms, creating the contamination risk that Criterion C is intended to avoid. The intervention is CPR training delivered as a program (VR experience or a short theoretical class), not one-to-one tutoring. Final sentence: Criterion C is not met because students were randomized individually rather than by class (or school), with no tutoring-style exception stated.
  • E

    Exam-based Assessment

    • The primary educational outcome used a study-specific set of multiple-choice questions rather than a widely recognized standardized exam.
    • "Knowledge. This is the main study variable. The same ten multiple-choice questions were used in all groups, with identical wording and scoring."
    • Relevant Quotes: 1) "Knowledge. This is the main study variable. The same ten multiple-choice questions were used in all groups, with identical wording and scoring." 2) "Although no separate validation study was conducted, all items were reviewed by experts in CPR education to confirm content equivalence." Detailed Analysis: Criterion E requires a standardized, widely recognized exam-based assessment (e.g., national/state standardized tests), not an instrument created or assembled specifically for the study. The paper describes the main outcome as "ten multiple-choice questions" used across groups. The authors note expert review but also state "no separate validation study was conducted," and they do not identify any widely recognized external standardized exam. Final sentence: Criterion E is not met because the study used a study-specific set of ten multiple-choice items rather than a recognized standardized exam.
  • T

    Term Duration

    • Outcomes were measured up to a twelve-month follow-up after the intervention began, which exceeds the minimum term-length requirement.
    • "A randomized trial was designed with three parallel lines and longitudinal follow-up at four different time points: pre-intervention (T-0), immediate assessment after the intervention (T-Immediate), follow-up after a month (T-Month), and after twelve months (T-Year)."
    • Relevant Quotes: 1) "A randomized trial was designed with three parallel lines and longitudinal follow-up at four different time points: pre-intervention (T-0), immediate assessment after the intervention (T-Immediate), follow-up after a month (T-Month), and after twelve months (T-Year)." 2) "The collection of data was performed between February 6th, 2024, and February 14th, 2025." Detailed Analysis: Criterion T requires educational outcomes to be measured at least one academic term (about 3–4 months) after the intervention begins (allowing short interventions, but requiring term-long follow-up). The paper specifies an "after twelve months (T-Year)" follow-up and provides concrete dates that span from February 2024 to February 2025. This is substantially longer than a single academic term. Final sentence: Criterion T is met because the study includes a twelve-month follow-up after the intervention began.
  • D

    Documented Control Group

    • The control group is clearly described (no intervention) and the paper reports group sizes and baseline characteristics for all groups (e.g., Table 1).
    • "Group 3: Control Group. This group did not receive training during the study but was assessed at the same time points."
    • Relevant Quotes: 1) "Group 3: Control Group. This group did not receive training during the study but was assessed at the same time points." 2) "Participants: 102 secondary school students (aged 14–15 years) from the Region of Murcia, Spain were randomly assigned to three groups (n = 34 each)." 3) "Table 1 shows the sociodemographic characteristics of the participating students." Detailed Analysis: Criterion D requires that the control group be well documented, including what it received (or did not receive), and information enabling baseline comparability (e.g., demographics and baseline measures). The paper explicitly defines the control condition as no training and states it was assessed at the same time points. It also reports allocation sizes and includes a baseline characteristics table (Table 1) covering demographics and relevant prior experience variables. Final sentence: Criterion D is met because the control group condition, allocation, and baseline characteristics are described.

• Level 2 Criteria

  • S

    School-level RCT

    • The trial was not randomized at the school level (it was conducted in a single school with individual-level assignment).
    • "Firstly, it was conducted in a single school, which benefitted the follow-up, but restricted the generalization of the findings to other contexts, levels of education, or regions."
    • Relevant Quotes: 1) "Firstly, it was conducted in a single school, which benefitted the follow-up, but restricted the generalization of the findings to other contexts, levels of education, or regions." 2) "The random assignment was performed individually, in a 1:1:1 ratio, through a sequence of random numbers generated by a computer (RAND function in Excel)." Detailed Analysis: Criterion S requires school-level (site-level) randomization across multiple schools/sites. The paper states the trial was conducted in a single school and that randomization was performed individually. With only one school and individual allocation, school-level randomization is not present. Final sentence: Criterion S is not met because the study used one school and randomized individuals rather than randomizing schools.
  • I

    Independent Conduct

    • Allocation concealment involved an independent researcher, but the paper does not show that the intervention evaluation was conducted by an external, independent team.
    • "The sequence was applied by an independent researcher, unrelated to the intervention and the collection of data, to maintain the allocation concealed."
    • Relevant Quotes: 1) "The sequence was applied by an independent researcher, unrelated to the intervention and the collection of data, to maintain the allocation concealed." 2) "The interpretation of results, statistical analyses, and all scientific conclusions were entirely performed and verified by the research team." Detailed Analysis: Criterion I requires the study to be conducted independently from the authors who designed the intervention, typically via third- party evaluators for implementation and/or data collection and analysis. The paper provides evidence of independence only for applying the randomization sequence (allocation concealment). It also states that interpretation and analyses were performed by the research team. The paper does not provide a clear statement that an external/independent evaluation team implemented the intervention and/or conducted outcome assessment and analysis independently of the intervention developers. Final sentence: Criterion I is not met because independence is only evidenced for allocation concealment, not for overall conduct and evaluation.
  • Y

    Year Duration

    • The study tracked outcomes from February 2024 to February 2025, which is approximately one full year and exceeds 75% of an academic year.
    • "The collection of data was performed between February 6th, 2024, and February 14th, 2025."
    • Relevant Quotes: 1) "A randomized trial was designed with three parallel lines and longitudinal follow-up at four different time points: pre-intervention (T-0), immediate assessment after the intervention (T-Immediate), follow-up after a month (T-Month), and after twelve months (T-Year)." 2) "The collection of data was performed between February 6th, 2024, and February 14th, 2025." Detailed Analysis: Criterion Y requires outcomes be measured at least 75% of one academic year after the intervention begins. The paper specifies a twelve-month follow-up (T-Year) and provides dates spanning roughly one year from February 2024 to February 2025. This exceeds the 75% threshold used by ERCT for a year-duration study. Final sentence: Criterion Y is met because the study includes a twelve-month follow-up with dates spanning about one year.
  • B

    Balanced Control Group

    • The intervention arms received additional instructional inputs (training time and VR equipment), while the control arm received no training; this imbalance is explicitly the intended treatment comparison (training vs no training).
    • "This study evaluated the effectiveness of a virtual reality (VR)- based cardiopulmonary resuscitation (CPR) training program compared with traditional theoretical instruction and a non-intervention control group, on improving and retaining knowledge, attitudes, and self-efficacy of secondary school students."
    • Relevant Quotes: 1) "This study evaluated the effectiveness of a virtual reality (VR)-based cardiopulmonary resuscitation (CPR) training program compared with traditional theoretical instruction and a non-intervention control group, on improving and retaining knowledge, attitudes, and self-efficacy of secondary school students." 2) "The scenario lasted approximately 10 min and covered key learning objectives, including safety assessment, consciousness and breathing checks, activation of Emergency Medical Services (EMS), chest compressions, and correct AED application (Supplementary Material 1)." 3) "Group 2: Traditional theoretical training Group. The students received a 10-minute in-person theoretical class about how to act during emergencies, with content that was equivalent to the VR group." 4) "Group 3: Control Group. This group did not receive training during the study but was assessed at the same time points." Detailed Analysis: Criterion B requires balanced time/resources across groups unless the extra time/budget/resources are explicitly the treatment variable being tested. Here, extra instructional inputs clearly exist: (a) the VR group used VR equipment and completed an approximately 10-minute VR scenario, and (b) the theoretical group received a 10-minute in-person class. The control group received no training. Under the ERCT criterion-B decision rule, this imbalance is acceptable if the study explicitly tests the effect of providing the additional educational resource itself (CPR training) versus a non-intervention control. The quoted objective and intervention descriptions show that the intended comparison includes a "non-intervention control group," i.e., the absence of the extra resources is part of the treatment definition rather than an unacknowledged confound. Final sentence: Criterion B is met because providing CPR training (including its time/equipment) is explicitly the treatment being tested against a non-intervention control group.

• Level 3 Criteria

  • R

    Reproduced

    • No independent replication of this specific trial was identified, and the paper itself does not report being replicated.
    • Relevant Quotes: None found in the paper text indicating this study was replicated by an independent team in a different context. Detailed Analysis: Criterion R requires an independent replication of the study (or a clearly stated replication of the same intervention/trial design) by a different research team, published in a peer-reviewed venue. This article reports a single randomized trial and does not describe an independent replication in the paper text. A search for replication studies specifically referencing and reproducing this exact trial did not identify any peer-reviewed replication papers. Final sentence: Criterion R is not met because no independent replication of this specific trial could be identified.
  • A

    All-subject Exams

    • Because the study does not use standardized exams (Criterion E is not met), it also cannot satisfy the all-subject standardized exam requirement.
    • Relevant Quotes: 1) "Knowledge. This is the main study variable. The same ten multiple-choice questions were used in all groups, with identical wording and scoring." Detailed Analysis: Criterion A requires measuring impact across all main subjects using standardized exam-based assessments, and it is explicitly dependent on Criterion E being met. This study uses a study-specific CPR knowledge questionnaire (ten multiple-choice questions) rather than standardized exams. Therefore, Criterion E is not met, which implies Criterion A is not met under the ERCT prerequisite rule. Final sentence: Criterion A is not met because the study does not use standardized exams (fails E), so it cannot meet the all-subject standardized exam requirement.
  • G

    Graduation Tracking

    • The study includes a twelve-month follow-up but does not report tracking participants until graduation; no follow-up graduation paper by the same authors was identified.
    • "A randomized trial was designed with three parallel lines and longitudinal follow-up at four different time points: pre-intervention (T-0), immediate assessment after the intervention (T-Immediate), follow-up after a month (T-Month), and after twelve months (T-Year)."
    • Relevant Quotes: 1) "A randomized trial was designed with three parallel lines and longitudinal follow-up at four different time points: pre-intervention (T-0), immediate assessment after the intervention (T-Immediate), follow-up after a month (T-Month), and after twelve months (T-Year)." 2) "Future studies should incorporate objective measurements of practical skills on CPR and AED use, explore retention in a longer term, and validate these findings with broader and multi-center samples." Detailed Analysis: Criterion G requires follow-up tracking until graduation from the relevant educational stage. (Also, because Criterion Y is met, the paper is eligible to be evaluated for G; it is not automatically disqualified by the ERCT dependency rule.) The paper clearly defines the longest follow-up as "after twelve months (T-Year)." It does not state that participants were tracked through graduation from their educational stage (e.g., completion of compulsory secondary education). Consistent with this, the authors discuss that future work should "explore retention in a longer term," implying that longer-term tracking (which could include graduation outcomes) was not performed here. A targeted search for subsequent cohort follow-up publications by the same author team reporting graduation outcomes for these participants did not identify any such paper. Final sentence: Criterion G is not met because the reported follow-up ends at 12 months and no graduation-tracking follow-up paper for this cohort was identified.
  • P

    Pre-Registered

    • The paper reports ethics approval and data-collection dates but does not state that a protocol was pre-registered or provide a registry ID and registration date.
    • Relevant Quotes: 1) "The study was approved by the Research Ethics Committee of the Catholic University of Murcia (UCAM), with code CE112309." 2) "The collection of data was performed between February 6th, 2024, and February 14th, 2025." Detailed Analysis: Criterion P requires an explicit statement of pre-registration, including a registry/platform and timing showing registration occurred before data collection began. The paper provides ethics approval information and clearly states the data-collection window. However, it does not provide a pre-registration registry name/link, a registration identifier, or a registration date. A targeted search for a publicly available pre-registration record corresponding to this trial did not locate a matching protocol entry. Final sentence: Criterion P is not met because no pre-registration registry, ID, or pre-data-collection registration timing is stated or could be verified.