CPR mannikins used in instructive social media posts lack diversity, influencing patient outcomes and disparities in training and care

Investigators found that there is a marked lack of diversity in the mannikins depicted by public social media accounts of organizations that administer cardiopulmonary (CPR) education. Less than 10% represented Black or Asian individuals and none represented pregnant women. Their study is published as a Research Letter opens in new tab/window in the Canadian Journal of Cardiology opens in new tab/window, an official journal of the Canadian Cardiovascular Society, published by Elsevier.

Out-of-hospital cardiac arrest (OHCA) is a leading cause of morbidity and mortality worldwide, placing a psychological burden on survivors, families, friends, healthcare providers, and entire communities. In the United States, there are approximately 356,000 OHCAs annually. Nearly 90% of these arrests are fatal. In Canada alone, nearly 35,000 OHCAs occur annually, and fewer than 10% of patients survive to hospital discharge. Several factors impact the outcomes of OHCA, with the main contributing factor being effective CPR.

The DIVERSE I study (Determining the Importance of Various gEnders, Races and body Shapes for CPR Education) demonstrated that although CPR training is intended to simulate cardiac arrest, most manufactured models (mannikins) represent white lean men, who are only a small proportion of individuals who actually experience OHCA.

The primary aim of the DIVERSE II study (Determining the Importance of Various gEnders, Races and body Shapes for CPR Education: Images in MedIa), reported here, was to determine the diversity of mannikins represented on the public social media accounts of institutions, businesses, and non-governmental organizations that administer CPR certification.

“Diversity training is an important target for CPR education as it would theoretically change the perception of sudden cardiac death in a broad population,” explained lead investigator Adrian Baranchuk, MD, Department of Medicine, Kingston Health Sciences Center, Queen’s University, Kingston, ON, Canada. “Social media platforms are becoming cornerstones of medical education for students, physicians, and the public. It is crucial that these educational tools are representative of the populations receiving CPR, so we decided to investigate these platforms further.”

Researchers identified organizations from North America (NA) and South America (SA) through a collaboration with the Interamerican Society of Cardiology and compiled these into a comprehensive database. They analyzed social media posts from September 1, 2019, to September 19, 2021, using a nine-question data collection Google form to collect details including platform used (Twitter/Instagram), date of post, country, body shape, age, apparent race, and perceived gender. All mannikin characteristics were ascertained at the discretion of the authors, with any conflicts resolved by consensus.

Pictured above: Apparent race, perceived gender and body shape of mannikins depicted in social media posts analyzed by researchers. Panel A: White and lean man, woman and black mannikin being used for CPR education. The mannikin representing the woman was identified using facial features and distinct female anatomy such as breasts. The mannikin representing the Black individual was identified using skin color and facial features. Panel B: % of posts per demographic characteristics (Credit: Canadian Journal of Cardiology).

In total, investigators collected 211 images of mannikins. From NA, 104 (49.3%) were identified and from SA, 107 (50.7%) were identified. Of these, only four (1.8%) used non-lean mannikins, 32 (15.2%) represented women, 14 (6.6%) represented children, eight (3.8%) represented black individuals, and three (1.4%) represented Asian individuals. None of the images represented pregnant women.

Overall, the researchers found there is a marked lack of diversity in the mannikins used by public social media accounts that advertise CPR education. “Awareness of this issue is crucial so that educational tools are representative of populations needing CPR in real life. Training should be different when treating patients such as infants or pregnant patients with varying CPR requirements,” noted Dr. Baranchuk.

“Future work should investigate solutions to minimize the implicit bias present in media posts of mannikins such as increasing the exposure to racially diverse mannikins with high frequencies to override preconceived notions. The link between improved mortality rates in diverse groups and an increase in bystander CPR rates with diverse individuals would be a future point of interest to study,” he concluded.

Recent North American estimates have shown that only 41% of OHCA patients receive bystander-initiated CPR, and fewer than 6% have an automated external defibrillator (AED) applied by a bystander before the arrival of professional responders, according to lead author Nicholas Grubic, MSc, Department of Medicine, Queen’s University, Kingston, ON, Canada, and coauthors in an accompanying editorial opens in new tab/window.

“The provision of care and survival after OHCA has been shown to differ by sociodemographic factors, most notably sex/gender and race,” they commented. “This study highlights a ‘real-world’ gap in sociodemographic diversity among health promotion media for OHCA. The paucity of mannikins representing non-lean, female or pregnant individuals identified by this analysis is concerning. This study provides important data to suggest that implicit biases in OHCA exist, and that these biases may influence disparities in OHCA training, care, and outcomes. Novel strategies that aim to alter historical perceptions of resuscitation and OHCA, which are rooted in cultural appropriation and lack of diversity, should be a public health priority.”

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Notes for editors

The article is “Research Letter: Determining the Importance of Various GEnders, Races and Body Shapes for CPR Education Using Mannikins: Images in MedIa (DIVERSE II),” by Shyla Gupta, BHSc, Reem Al-Rawi, Pablo Iomini, MD, Josefina Fitz Maurice, BSc, Tomas Fitz Maurice, Mario Fitz Maurice, MD, Juan M. Farina, MD, Kiera Liblik, MSc, and Adrian Baranchuk, MD, FACC, FRCPC, FCCS, FSIAC (https://doi.org/10.1016/j.cjca.2022.09.023 opens in new tab/window).

The editorial is “Removing the “Man” in “Mannikin”: The Importance of Sociodemographic Diversity in Resuscitation Training,” by Nicholas Grubic, MSc, Brendan T. Smith, PhD, Varinder K. Randhawa, MD, PhD, Audrey L. Blewer, PhD, MPH, and Katherine S. Allan, PhD (https://doi.org/10.1016/j.cjca.2022.10.016 opens in new tab/window).

Both articles appear online ahead of the Canadian Journal of Cardiology, volume 38 issue 12 (December 2022) published by Elsevier.

Full text of the articles is available to credentialed journalists upon request. Contact Eileen Leahy at +1 732 238 3628 or [email protected] opens in new tab/window to obtain copies. Journalists wishing to speak to the study’s authors should contact at Dr. Adrian Baranchuk opens in new tab/window. To reach the editorial’s authors for comment, contact Nicholas Grubic opens in new tab/window.

About the Canadian Journal of Cardiology

The Canadian Journal of Cardiology opens in new tab/window is the official journal of the Canadian Cardiovascular Society opens in new tab/window. It is a vehicle for the international dissemination of new knowledge in cardiology and cardiovascular science, particularly serving as a major venue for the results of Canadian cardiovascular research and Society guidelines. The journal publishes original reports of clinical and basic research relevant to cardiovascular medicine as well as editorials, review articles, case reports, and papers on health outcomes, policy research, ethics, medical history, and political issues affecting practice.

About the Editor-in-Chief

Editor-in-Chief Stanley Nattel, MD, is Paul-David Chair in Cardiovascular Electrophysiology and Professor of Medicine at the University of Montreal and Director of the Electrophysiology Research Program at the Montreal Heart Institute Research Center.

About the Canadian Cardiovascular Society (CCS)

The CCS opens in new tab/window is the national voice for cardiovascular clinicians and scientists, representing more than 2,300 cardiologists, cardiac surgeons and other heart health specialists across Canada. We advance heart health for all by setting standards for excellence in heart health and care, building the knowledge and expertise of the heart team, and influencing policy and advocating for the heart health of all Canadians. For further information on the CCS visit https://ccs.ca/ opens in new tab/window.

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