CPR manikin diversity for BLS education: Current status mapped by an international cross-sectional survey and steps to reach health equity.

Background
Certain community groups receive less bystander Basic Life Support (BLS). To improve that it was proposed to include in BLS training manikins representing diverse groups, as in current BLS training most manikins are white, lean and male/flat-chested. However, instructors attitudes about the use of diverse manikins and their distribution worldwide are unclear.

Methods
A cross-sectional survey was distributed in international resuscitation networks and national resuscitation councils. Data from participating organisations and manikin characteristics used for BLS training were analysed, and differences between countries from different income classification were assessed.

Results
After de-duplication and removal of incomplete responses, data of 133 organisations from 43 countries from six continents reporting on 5,364 manikins were analyzed. Most organisations (55%) use only white, male/flat-chested, lean manikins. Non-white manikins were the most commonly used diversification (33% of participating organisations). Only 20% of organisations use female manikins. Greater diversification is thought to enhance realism in training, promote inclusivity, and allows participants to be more aware of real-world situations involving diverse patient populations. Barriers described were high costs, low awareness towards the need of manikin diversity, institutional resistance to changes, and limited evidence on the impact of diversification.

Conclusion
The vast majority of reported adult and pediatric CPR manikins are white, male/flat-chested, and lean, and thus lack diversification. Almost one-fifth of respondents indicated to put a bra on a "standard" manikin to simulate a female manikin. Research into diversified manikin use, how to overcome barriers, and its impact on educational and clinical outcomes are needed.