Cardiac arrest (CA) is one of the leading medical emergencies worldwide, characterized by the sudden cessation of effective cardiac activity, resulting in the absence of circulation and respiration, leading to imminent death if not promptly treated [1]. It is estimated that millions of cases occur annually, a substantial proportion of which take place in out-of-hospital settings [2].

In Brazil, according to estimates from the Brazilian Society of Cardiology, approximately 200,000 cases of CA occur each year, most of them outside the hospital environment [3]. In the United States, data from the Cardiac Arrest Registry to Enhance Survival (CARES) indicate that >350,000 out-of-hospital CAs occur annually, with overall survival to hospital discharge remaining close to 10% [4].

Immediate cardiopulmonary resuscitation (CPR) performed by bystanders has been shown to double or even triple survival rates and improve neurological outcomes [5,6]. Conversely, for every minute without CPR, survival decreases by approximately 7% to 10%, underscoring the critical importance of early intervention [5]. When CPR is initiated promptly, outcomes may improve substantially, depending on response time and quality of care [4,5]. Despite the strong evidence supporting bystander CPR, intervention rates remain suboptimal, particularly in low- and middle-income countries, where cultural, structural, and educational barriers limit its dissemination [7,8]. These findings highlight the need for community-based educational strategies aimed at increasing the number of trained lay responders.

Training laypeople in CPR is recognized as one of the most effective strategies to improve survival after CA [6,9]. The American Heart Association and the European Resuscitation Council advocate for widespread Basic Life Support (BLS) training, including initiatives within school environments [5,10]. In this context, the international “Kids Save Lives” initiative, endorsed by the World Health Organization, recommends mandatory CPR training in schools starting at the age of 12 years [11].

International experiences have demonstrated that incorporating CPR training into school curricula is associated with increased rates of bystander intervention and improved survival outcomes after CA [12,13]. Studies have shown that schoolchildren from the age of 12 years are capable of acquiring basic CPR knowledge and skills and may act as multipliers of health-related practices within their communities [14,15].

In Brazil, the dissemination of CPR training remains limited. Law No 13,722/2018 established mandatory first aid training for teachers and staff in educational institutions [16]. Although this legislation represents an important advance, its implementation remains heterogeneous across educational settings and does not directly include structured CPR training programs targeting children and adolescents, who constitute a strategic population due to their potential for early learning and community impact [12].

The effectiveness of health education programs extends beyond the transmission of theoretical knowledge and may contribute to the development of competencies encompassing cognitive, psychomotor, and attitudinal domains [17]. In the context of CPR training, this includes not only understanding the principles and steps of resuscitation but also the ability and willingness to apply them appropriately in real-life situations [17,18].

As CPR training initiatives continue to expand, there is an increasing need for instruments capable of objectively evaluating their educational outcomes [17]. However, the valid and reliable assessment of CPR-related knowledge, attitudes, and practical skills remains challenging [17,18]. This challenge is particularly evident among children and adolescents, for whom there is a scarcity of specifically developed assessment tools [19]. In many cases, questionnaires originally designed for adults are applied or adapted without adequate methodological rigor, potentially compromising content validity, sensitivity to the learning process, and comparability across studies [20–23]. Moreover, cultural and linguistic differences may influence comprehension and interpretation, highlighting the importance of culturally adapted and validated instruments [21–23].

Among the instruments available for assessing CPR-related educational outcomes in school settings, the questionnaire developed by Pivač et al. in Slovenia and published in 2020 was specifically designed for schoolchildren aged 12 to 15 years [24]. The instrument includes structured questions addressing key components of basic life support, such as recognition of cardiac arrest, activation of emergency medical services, chest compressions, and automated external defibrillator use, as well as items exploring attitudes toward helping behaviors and willingness to provide CPR. The original authors reported pilot testing and content validity assessment during instrument development. Its focus on adolescents, applicability to school-based educational interventions, and comprehensive assessment of CPR-related educational outcomes supported its selection for cross-cultural adaptation to the Brazilian context [24].

Thus, the aim of this study was to translate and cross-culturally adapt this questionnaire into Brazilian Portuguese for the assessment of CPR-related knowledge and attitudes among adolescents.

This study successfully achieved its primary objective of translating and cross-culturally adapting the questionnaire developed by Pivač et al. [24] for use among Brazilian adolescents. Following internationally recognized recommendations for cross-cultural adaptation, the process resulted in a Brazilian Portuguese version that preserved the semantic, idiomatic, cultural, and conceptual equivalence of the original instrument while demonstrating satisfactory content validity. These findings support the use of the adapted questionnaire as an appropriate tool for assessing CPR-related knowledge and attitudes among Brazilian adolescents [23,26].

The content validity observed in the present study (S-CVI/Ave = 0.92) indicates a high level of agreement among experts and is consistent with findings from previous methodological studies involving the adaptation of health-related instruments. According to Polit and Beck, S-CVI values above 0.90 are considered indicative of excellent content validity, reinforcing the robustness of the adapted version [25]. A comparable contribution to the field was provided by Gradvohl et al., who developed and validated a questionnaire specifically designed to assess resuscitation-related knowledge and attitudes among adolescents [20]. Similar to the present investigation, their study addressed the need for age-appropriate instruments capable of evaluating educational outcomes associated with school-based CPR training. However, important methodological distinctions should be acknowledged. Whereas Gradvohl et al. focused on the development and psychometric validation of a novel instrument within its original cultural context, the present study was designed to translate and cross-culturally adapt an existing questionnaire previously developed for adolescents. Consequently, the authors’ objective was not to establish the psychometric properties of a newly developed instrument, but rather to ensure semantic, idiomatic, cultural, and conceptual equivalence while preserving the theoretical constructs underlying the original version.

Despite these methodological differences, both investigations underscore the importance of rigorously developed and population-specific assessment tools for strengthening the evaluation of CPR educational interventions among adolescents [20].

Although the overall S-CVI/Ave was excellent, seven items initially presented I-CVI values below the recommended threshold and therefore required revision. Rather than representing a weakness of the adaptation process, these findings highlight the importance of expert evaluation in identifying linguistic and cultural nuances that could influence item interpretation. The iterative revision process allowed these issues to be addressed while preserving the conceptual meaning of the original questionnaire, ultimately strengthening the quality of the final version [23,25,26].

The modifications performed throughout the adaptation process primarily involved adjustments in terminology, wording, and cultural references to ensure comprehension and contextual appropriateness for Brazilian adolescents. This finding reinforces the premise that linguistic equivalence alone is insufficient to guarantee the validity of an instrument across different cultural settings. As emphasized by Beaton et al. and Guillemin et al., successful cross-cultural adaptation requires preserving the conceptual intent of each item while ensuring that the target population interprets the content as originally intended [22,23]. The structured methodology adopted in this study contributed to maintaining the integrity of the original constructs while improving cultural relevance and comprehensibility.

The selection of the questionnaire developed by Pivač et al. [24] was particularly appropriate because the original instrument was specifically designed to evaluate CPR-related knowledge and attitudes among school-aged adolescents following educational interventions in basic life support. Unlike instruments originally developed for adults and subsequently applied to younger populations, the questionnaire was conceived within an educational context targeting adolescents. Consequently, the adaptation process required predominantly linguistic and cultural adjustments rather than substantial conceptual modifications, supporting the preservation of the theoretical constructs assessed by the original instrument.

The findings of this study are aligned with international evidence emphasizing the importance of validated instruments in the evaluation of CPR training programs, particularly in school settings [11,13,21,24,27]. The incorporation of CPR education into school curricula has been strongly recommended by organizations such as the World Health Organization and the European Resuscitation Council, which advocate the implementation of regular CPR training beginning in adolescence [5,10,11]. In this context, the availability of reliable and culturally adapted assessment tools is essential for measuring educational outcomes, monitoring program effectiveness, and supporting the development of evidence-based educational strategies.

Recent studies have demonstrated that school-based CPR training significantly improves knowledge acquisition and practical skills among adolescents, contributing to increased willingness to intervene in emergency situations and potentially improving survival after out-of-hospital cardiac arrest [12,14]. Nevertheless, despite growing international support for CPR education in schools, important barriers to implementation remain, particularly in low- and middle-income countries [8]. In Brazil, although Law No 13,722/2018 expanded first-aid training requirements for school personnel, structured CPR education programs directed at students remain limited and heterogeneous. Additional challenges may include variability in school infrastructure, limited availability of trained instructors and educational resources, competing curricular priorities, and insufficient public awareness regarding the importance of bystander CPR [7,16]. These challenges reinforce the need for validated instruments capable of systematically evaluating educational initiatives and generating evidence to support future implementation efforts.

The results of the pre-test further support the adequacy of the adapted instrument. Adolescents demonstrated a high level of comprehension and reported no significant difficulties in understanding the questionnaire items. This finding is particularly relevant because clarity and accessibility of language are fundamental characteristics of self-reported measures intended for younger populations [26]. Ensuring that questionnaire items are easily understood reduces the likelihood of response bias and contributes to the reliability and accuracy of the collected data.

From an educational perspective, it is important to recognize that the present instrument evaluates only specific dimensions of CPR competence. The questionnaire primarily assesses cognitive aspects related to CPR knowledge and selected attitudinal components. However, contemporary educational frameworks emphasize that professional and layperson competence encompasses multiple domains, including knowledge, psychomotor skills, attitudes, and behavioral readiness [18,19]. Therefore, although the adapted questionnaire represents an important tool for evaluating learning outcomes, it should not be interpreted as a comprehensive measure of overall CPR competence.

Current evidence suggests that knowledge acquisition alone may not be sufficient to ensure effective action during a real cardiac arrest event. Factors such as self-efficacy, confidence, willingness to intervene, and psychomotor performance play critical roles in determining bystander response [17]. Consequently, future studies evaluating CPR educational programs among adolescents should consider combining the present questionnaire with complementary assessment methods, such as practical skill checklists, simulation-based performance assessments, and self-efficacy measures, to obtain a more comprehensive evaluation of CPR-related competencies [17,19,27].

This study has some limitations that should be acknowledged. First, the research focused on translation, cross-cultural adaptation, and content validity, without evaluating additional psychometric properties such as internal consistency, test-retest reliability, responsiveness, and construct validity. These properties are essential for establishing the overall measurement quality of the instrument and should be investigated in future studies. Second, the pre-test was conducted in a single educational setting, which may limit the generalizability of the findings to other regions and educational contexts in Brazil. Third, although the expert committee included professionals with extensive experience in emergency medicine, medical education, and research methodology, all members were physicians. The inclusion of experts from other disciplines might have provided complementary perspectives regarding educational and measurement-related aspects of the instrument. Nevertheless, the expertise represented within the committee was considered appropriate for evaluating the semantic, idiomatic, cultural, and conceptual equivalences required during the cross-cultural adaptation process.

Despite these limitations, the study presents important strengths. The use of a rigorous methodological framework based on internationally recognized recommendations ensured transparency and reliability throughout the adaptation process [22,23]. The participation of an expert committee with extensive experience in emergency medicine and medical education contributed to the quality of the content validation. Furthermore, the inclusion of adolescents during the pre-test phase ensured that the final version was evaluated within its target population, enhancing its practical applicability. Taken together, these strengths support the use of the adapted questionnaire as a valuable tool for future research and educational initiatives aimed at promoting CPR training among Brazilian adolescents.

The questionnaire was successfully translated and cross-culturally adapted into Brazilian Portuguese through a rigorous methodological process. The adapted version demonstrated adequate semantic, idiomatic, cultural, and conceptual equivalence, satisfactory content validity, and good comprehensibility among Brazilian adolescents.

The present findings provide initial evidence supporting the suitability of the instrument for use in the Brazilian context. However, further studies evaluating reliability, construct validity, and other psychometric properties are required before broader implementation in research and educational programs. Such investigations will contribute to establishing the instrument as a robust tool for assessing CPR-related knowledge among Brazilian adolescents.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The data that support the findings of this study are available from the corresponding author.