---
title: "CPR knowledge and confidence gaps in Malaysian university students — peer-led workshop outcomes"
id: "plos-one-9-knowledge-willingness-and-self-efficacy-in-cpr-a-two-phase-study-of-prevalence"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-9-knowledge-willingness-and-self-efficacy-in-cpr-a-two-phase-study-of-prevalence"
content_type: "clinical_feed_article"
specialty: "Critical Care"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0360510"
published_at: "2026-10-12T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# CPR knowledge and confidence gaps in Malaysian university students — peer-led workshop outcomes
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-9-knowledge-willingness-and-self-efficacy-in-cpr-a-two-phase-study-of-prevalence
- **Specialty:** [Critical Care](https://medichelpline.com/clinical-feed/critical-care.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0360510)
- **Published At:** 2026-10-12T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- The study used a validated KABSE (Knowledge, Attitude, Behavioral Intention, Self-Efficacy) questionnaire to assess CPR preparedness among university-affiliated participants; Phase 1 enrolled 431 respondents and Phase 2 enrolled 33 for a peer-led workshop. - Baseline medians in Phase 1: knowledge 50% (IQR 33–67), attitude 83% (IQR 73–95), behavioral intention 75% (IQR 63–88), self-efficacy 31% (IQR 19–50); attitudes and willingness exceeded knowledge and confidence. - Major reported barriers to training were not knowing where to learn (30.2%) and lack of time (29.9%); main reasons for unwillingness to perform CPR included fear of causing harm (73.3%) and fear of legal repercussions (46.6%). - Females had higher knowledge and attitude scores; males reported greater self-efficacy. Older and married participants showed more positive attitudes. Healthcare-related academic background correlated with higher knowledge, attitude, and self-efficacy but similar behavioral intention to non-health peers. - AED awareness, AED usage capability, and recent CPR training were linked to higher KABSE scores (reported significance p < 0.001). - Correlations: knowledge–attitude r = 0.297, knowledge–self-efficacy r = 0.213, attitude–behavioral intention r = 0.477 (all p < 0.001). - Phase 2 peer-led, two-hour workshop (medical student instructors, theory plus hands-on stations) produced statistically significant pre–post improvements across all domains: knowledge rose from median 58.33% to 91.67%, self-efficacy from 50% to 75%; reported effect sizes were large for knowledge and self-efficacy. - The workshop was a feasible proof-of-concept; authors reported short-term, self-reported gains but no formal practical performance metrics were analyzed or reported. - The source reported ethical approval and convenience sampling; it noted limitations including small Phase 2 sample, non-randomized design, self-selection bias, reliance on self-reported outcomes, and lack of long-term retention or objective performance assessment.
## Clinical Analysis & Structured Key Points
Knowledge, willingness, and self-efficacy in CPR: A two-phase study of prevalence and preliminary peer-led workshop in a Malaysian tertiary institution | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract Background Out-of-hospital cardiac arrest remains a major public health concern, and early cardiopulmonary resuscitation (CPR) by bystanders is crucial for improving survival outcomes. University students represent an important target population for CPR education because they are socially active, highly accessible, and capable of disseminating lifesaving knowledge within the wider community. However, inadequate CPR knowledge, low willingness to perform CPR, and poor self-efficacy remain common among university students in Malaysia. Objectives This two-phase study aims to determine the prevalence of self-reported CPR-related knowledge, willingness, and self-efficacy among students in a Malaysian tertiary institution (Phase 1) and to explore the preliminary changes in these outcomes following a peer-led CPR workshop (Phase 2). Methods In Phase 1, a cross-sectional survey was conducted at a tertiary institute in Selangor, Malaysia using a validated questionnaire on knowledge, attitudes, behavioral intention, and self-efficacy (KABSE) (N = 431). In Phase 2, a two-hour peer-led workshop, delivered by medical students, targeted students without CPR training in the past two years, and pre–post KABSE changes were measured (N = 33). Results Phase 1 baseline findings revealed CPR knowledge and self-efficacy levels were relatively lower than attitudes and willingness to perform CPR. Females showed higher knowledge and attitudes, while males reported greater self-efficacy. Older and married participants demonstrated better attitudes, and those with a healthcare-related background had higher knowledge, attitudes, and self-efficacy, though similar behavioral intention. Higher scores were also linked to AED awareness, AED usage capability, and recent CPR training. Statistical analysis revealed significant associations among the KABSE domains. Following the peer-led workshop, the participants showed significant gains in self-reported knowledge (p < 0.001), attitude (p < 0.001), behavioral intention (p < 0.01), and self-efficacy (p < 0.001). Conclusion Although participants displayed positive attitudes toward CPR, baseline knowledge and self-efficacy were limited. The peer-led workshop demonstrated feasibility as a proof-of-concept intervention, generating significant short-term gains in self-reported knowledge and confidence. Citation: Lee S-K, Hoo LJ, Koh Raj RZ, Yeo IKL, Beh YW, Ibrahim R, et al. (2026) Knowledge, willingness, and self-efficacy in CPR: A two-phase study of prevalence and preliminary peer-led workshop in a Malaysian tertiary institution. PLoS One 21(10): e0360510. https://doi.org/10.1371/journal.pone.0360510 Editor: Nik Hisamuddin Nik Ab. Rahman, Universiti Sains Malaysia, MALAYSIA Received: May 28, 2026; Accepted: September 28, 2026; Published: October 12, 2026 Copyright: © 2026 Lee et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The original contributions presented in this study are included in the article. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Introduction Out-of-hospital cardiac arrest (OHCA) is a time-critical emergency with high mortality, particularly when immediate intervention is lacking. Cause can be cardiac (e.g., acute myocardial infarction, malignant arrhythmias, cardiomyopathies, and severe heart failure) and non-cardiac (e.g., airway obstruction, drowning, trauma, electrocution, drug overdose, and massive hemorrhage) Unlike in-hospital cardiac arrests, OHCA outcomes rely heavily on rapid recognition, prompt activation of emergency medical services (EMS), and timely bystander cardiopulmonary resuscitation (CPR) [ 1 – 5 ]. Survival following cardiac arrest declines by approximately 7–10% for every minute that ventricular arrhythmia remains untreated [ 6 ]. This makes timely bystander CPR the single most effective intervention in bridging the gap until EMS arrives. Globally, bystander CPR rates vary dramatically depending on local emergency systems and public education initiatives, ranging from 1.3 to 72% [ 7 ]. High-income Western nations often report layperson CPR rates exceeding 50–70% [ 8 ], whereas regional Asian counterparts such as Singapore (~59%) and South Korea (~47%) have achieved substantial gains through nationwide public-access training and automated dispatch initiatives [ 9 ]. In Malaysia, however, bystander CPR engagement remains relatively low at approximately 38%, while automated external defibrillator (AED) utilization is under 1.5% [ 10 ]. Coupled with mean EMS response times of roughly 12 minutes, which exceeding the recommended 8 minutes window [ 10 , 11 ], this low bystander intervention rate creates a critical pre-hospital gap that severely undermines OHCA survival outcomes nationally [ 12 ]. Determinants of willingness to perform CPR/AED include demographics, prior training, attitudes, self-efficacy, and legal protection. Positive factors are younger age, male gender, higher education, recent CPR/AED training, repeated exposure, and confidence [ 2 – 5 ]. Barriers include fear of litigation, harming the victim, and misconceptions that only medical professionals should perform CPR [ 3 , 4 ]. While training improves knowledge and willingness [ 13 ], participation is often hindered by cost, travel, and time commitments [ 14 ]. In Malaysia, current public health initiatives related to CPR have predominantly targeted medical and healthcare professionals, with limited availability of training opportunities for the public. In this context, colleges or universities represent an untapped yet promising platform for CPR education. As institutions composed of individuals from diverse academic, cultural, and socioeconomic backgrounds, universities mirror the broader Malaysian society. More importantly, they provide a structured and supportive environment that is ideal for implementing systematic CPR training and awareness initiatives. Students, lecturers, and staff are often in the age group that is both likely to witness and respond to OHCA incidents, whether in university, at home, or in public settings. The most accessible and practical time to equip individuals with life-saving CPR skills is during their university years, a period marked by openness to learning and exposure to health campaigns and co-curricular development. Furthermore, once students graduate, they disperse into various sectors and locations across Malaysia and globally, making them powerful carriers of CPR knowledge and readiness. Despite the potential of this setting, the wider university community including students from non-health faculties remains relatively neglected in CPR-related studies. These individuals are equally likely to be present during cardiac emergencies but may lack the basic competencies or willingness to intervene [ 2 , 15 ]. This oversight presents a critical gap in both academic research and national preparedness for OHCA. Variables such as academic discipline, age, gender, prior CPR exposure, and awareness of emergency protocols may influence a person’s preparedness to act. These associations remain underexplored, and addressing this gap is essential for developing targeted, inclusive and peer-led CPR workshops across campus communities. Therefore, Phase 1 of this study aimed to examine the levels of CPR-related knowledge, willingness, and self-efficacy among the university community and to explore the relationship between these levels and various sociodemographic characteristics. Phase 2 explored a brief peer-led CPR workshop as a proof-of-concept educational approach, focusing on preliminary changes in CPR knowledge, willingness, and self-efficacy following the training. Together, the two phases provide an initial understanding of CPR preparedness within the university community and the potential of peer-led training to address identified gaps in CPR knowledge, willingness to perform CPR, and self-efficacy. Methods Study design and ethical considerations This study was conducted in strict accordance with the ethical standards set forth by the institutional ethics committee to ensure the protection, rights, and confidentiality of all participants. Ethical approval was obtained from the Universiti Tunku Abdul Rahman Scientific and Ethical Review Committee (Approval Number: U/SERC/78–546/2025). The subject recruitment period was from 27/06/2025 to 31/08/2025. Written informed consent was obtained from all participants prior to their enrolment in the study. Survey instrument and participant recruitment Both Phase I and II employed a self-administered questionnaire previously validated in the literature. The instrument comprised five main sections assessing knowledge, attitude, behavioral intention, and self-efficacy, demonstrating high content validity (content validity index = 0.95) and high internal consistency (Cronbach’s alpha = 0.92) [ 16 ]. Participants for the Pilot Study, Phase 1, and Phase 2 were recruited using convenience sampling through an e-mail announcement disseminated via the university’s Mail-Master system. Participation was voluntary, and eligible individuals self-selected to participate. participants were eligible if they were aged 18 years or above, able to read and understand English, and able to provide informed consent. Pilot study Prior to commencement of the main study, a pilot study with 30 participants was conducted to re-evaluate the clarity, feasibility, and reliability of the KABSE questionnaire, yielding Cronbach’s alpha coefficients exceeding 0.95 across all domains. Given the small sample size, this pilot was not intended to re-establish full psychometric validity, but ensured the questionnaire was understandable and reliable prior to use in the main study. Phase 1 Study: Assessment of KABSE and its association with sociodemographic determinants Participants who had participated in the Pilot Study were excluded from Phase 1. Recruited participants completed the self-administered KABSE questionnaire to assess their knowledge, attitude, behavioral intention, and self-efficacy toward CPR. Sociodemographic information was also collected for subsequent analysis of the associations between participant characteristics and KABSE scores. Phase 2 Study: Pre- and post-workshop assessment A quasi-experimental intervention design was employed in Phase 2. This design was selected because participants were not randomly assigned; instead, they voluntarily enrolled in the peer-led CPR workshop. Participants who had participated in the Pilot Study and Phase 1 were excluded from Phase 2 to minimize potential testing and carryover effects. Participants were required to have no formal recent CPR training within the preceding two years. Recent CPR training was operationally defined as training received within the preceding two years. This cutoff was selected pragmatically to represent relatively recent CPR exposure, considering that CPR certification commonly has a validity period of two years. Nevertheless, this classification was not intended to imply that CPR-related knowledge, willingness, or self-efficacy ceases to be retained after 2 years, but rather to distinguish relatively recent training exposure from more remote training experience. All eligible participants completed pre- and post-intervention assessments to evaluate changes in knowledge, attitude, behavioral intention, and self-efficacy toward CPR following the training. The training was facilitated by four peer instructors, all of whom were Year 2 medical students and certified first aiders. Prior to leading the workshop, they successfully completed a refresher Basic Life Support (BLS) Provider course delivered by an emergency medicine specialist and organized by the Selangor Committee on Resuscitation Training (SCORT). All peer instructors achieved passing standards in both theoretical and practical assessments. This specialist-led preparation ensured their competence to deliver high-quality CPR instruction. Upon arrival, participants completed a pre-workshop questionnaire to collect sociodemographic information and baseline KABSE scores. The workshop began with a theory session covering the chain of survival, BLS steps, and choking response protocols. This was followed by a practical component conducted at two stations: Station 1 (choking management) and Station 2 (CPR training). Participants were divided into two large groups, rotating between stations after 25 minutes. Within the CPR station, smaller subgroups of four to five participants practiced complete CPR cycles and the recovery position on manikins under close observation. Each participant underwent hands-on CPR training guided by a standardized BLS performance checklist covering seven critical domains: Danger, Response, Shout for Help, Airway, Breathing, Circulation, and Pulse Check. The checklist was used by trainers as an instructional guide to ensure consistent demonstration and practice of the key steps of CPR. Throughout the practical session, participants received immediate, individualized feedback to facilitate timely correction of errors and reinforce proper technique. No written evaluation of participants’ practical performance was conducted or analyzed. At the choking station, participants were taught and practiced both conscious and unconscious choking management using a choking mannequin and live models. Each participant’s performance was directly observed, and immediate corrective feedback was provided to ensure proper technique and reinforce key safety principles. After completing both the theory and practical sessions, participants filled out the post-workshop KABSE questionnaire. The entire training lasted approximately two hours and was provided free of charge. Knowledge was measured through a 12-single best answer questions related to CPR, a correct response was awarded one mark, while incorrect or unanswered questions were was given zero marks, with higher scores indicating greater knowledge. Attitude, behavioral intention, and self-efficacy toward CPR were measured using a 5-point Likert scale ranging from 1 (strongly disagree/strongly unwilling/not confident at all) to 5 (strongly agree/strongly willing/extremely confident). Item scores were summed up to produce domain totals, with higher scores indicating more positive attitudes, stronger behavioral intention, and greater self-efficacy. The total scores for Knowledge, Attitude, Behavior and Self-Efficacy domains were transformed into percentage scores to permit comparisons across domains with differing item counts. Statistical analysis Data were analyzed using IBM SPSS Statistics Version 30.0. The distribution of continuous variables was assessed using the Kolmogorov–Smirnov test. As p-values were less than 0.05, the data were considered non-normally distributed and are presented as medians with interquartile ranges (IQRs) and further analyzed with non-parametric tests. Differences in KABSE scores across sociodemographic groups were examined using the Mann-Whitney U test for comparisons between two groups and the Kruskal-Wallis test for comparisons among more than two groups, followed by Bonferroni-adjusted pairwise comparisons where appropriate. Spearman’s rank correlation was applied to assess relationships between KABSE components. While The Wilcoxon signed-rank test was used to compare pre- and post-workshop KABSE scores. Subsequently, Cohen’s effect size was determined and interpreted as small (0.10–0.29), moderate (0.30–0.49), and large (≥0.50) [ 17 ]. Results Phase 1 Study: Assessment of KABSE and its association with sociodemographic determinants A total of 431 participants were enrolled into Phase 1 study. Median (IQR) baseline scores were as follows: knowledge 50.00 (33–67), attitude 83.00 (73–95), behavioral intention 75.00 (63–88), and self-efficacy 31.00 (19–50) ( Table 1 ). Individual item for each KABSE domain is reported in Supplementary Data ( S1 – S4 Tables ). Download: PNG larger image TIFF original image Table 1. Median scores in knowledge on CPR, attitude towards CPR, behavioral intention in performing CPR, and self-efficacy in performing CPR. https://doi.org/10.1371/journal.pone.0360510.t001 The main barriers to training included lack of knowledge of where to learn (30.2%) and time constraints (29.9%) ( Table 2 ). The most frequently cited reason for unwillingness to perform CPR was concern about causing harm due to lack of hands-on experience, reported by 316 participants (73.3%). Fear of legal repercussions was the second most common reason (46.6%), followed by discomfort in performing mouth-to-mouth resuscitation on a stranger (38.1%). Other barriers included fear of contracting infections or diseases when assisting strangers (30.2%) and concern about being judged for performing CPR incorrectly (29%) ( Table 3 ). Download: PNG larger image TIFF original image Table 2. Reasons for not attending CPR training. https://doi.org/10.1371/journal.pone.0360510.t002 Download: PNG larger image TIFF original image Table 3. Reasons for unwillingness to perform CPR. https://doi.org/10.1371/journal.pone.0360510.t003 Females demonstrated higher levels of knowledge and more positive attitudes compared to males; however, males reported greater self-efficacy. Older and married participants showed better attitudes toward CPR. Participants with an academic healthcare-related background (Medicine, Chinese Medicine, Physiotherapy or Nursing) consistently exhibited higher knowledge, attitudes, and self-efficacy, although their behavioral intention to perform CPR was comparable to those without such an academic background. Higher knowledge, attitude, and self-efficacy scores were also associated with AED awareness, AED usage capability, and recent CPR training (p < 0.001) ( Table 4 ). Download: PNG larger image TIFF original image Table 4. Significance difference between KABSE and sociodemographic factors and CPR training exposure. https://doi.org/10.1371/journal.pone.0360510.t004 Significant positive correlations were observed between knowledge and attitude (r = 0.297, p < 0.001), knowledge and self-efficacy (r = 0.213, p < 0.001), and attitude and behavioral intention (r = 0.477, p < 0.001). Phase 2 study: Pre- and post-workshop assessment A total of 33 participants were enrolled into Phase 2 study. As shown in Table 5 , all KABSE domains improved significantly after the workshop. Knowledge increased from a median of 58.33 to 91.67 with a large effect size (r = 0.853). Attitude improved with a moderate effect size (r = 0.578), while behavioral intention showed a moderate effect (r = 0.476). Self-efficacy increased from 50.00 to 75.00 with a large effect size (r = 0.794). All changes were statistically significant, the effect sizes demonstrate that the magnitude of improvement, particularly for knowledge and self-efficacy was practically meaningful ( Table 5 ). Download: PNG larger image TIFF original image Table 5. Median Scores in knowledge, attitude, behavioral intention, and self-efficacy towards CPR pre and post the workshop. https://doi.org/10.1371/journal.pone.0360510.t005 Discussion This study found that despite generally positive attitudes and behavioral intentions towards CPR, participants demonstrated lower knowledge and self-efficacy. The
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