Knowledge and Attitudes Towards Basic Life Support Among Health Students at a Saudi Women ’ s University

OBJECTIVES
Awareness of basic life support (BLS) is paramount to ensure the provision of essential life-saving medical care in emergency situations. This study aimed to measure knowledge of BLS and attitudes towards BLS training among female health students at a women's university in Saudi Arabia.


METHODS
This prospective cross-sectional study took place between January and April 2016 at five health colleges of the Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia. All 2,955 students attending the health colleges were invited to participate in the study. Participants were subsequently asked to complete a validated English-language questionnaire which included 21 items assessing knowledge of BLS and six items gauging attitudes to BLS.


RESULTS
A total of 1,349 students completed the questionnaire (response rate: 45.7%). The mean overall knowledge score was very low (32.7 ± 13.9) and 87.9% of the participants had very poor knowledge scores. A total of 32.5% of the participants had never received any BLS training. Students who had previously received BLS training had significantly higher knowledge scores (P <0.001), although their knowledge scores remained poor. Overall, 77.0% indicated a desire to receive additional BLS training and 78.5% supported mandatory BLS training.


CONCLUSION
Overall knowledge about BLS among the students was very poor; however, attitudes towards BLS training were positive. These findings call for an improvement in BLS education among Saudi female health students so as to ensure appropriate responses in cardiac arrest or other emergency situations.

0][11][12] This study therefore aimed to evaluate knowledge and attitudes towards BLS among Saudi female health students at the Princess Nourah bint Abdulrahman University (PNU) in Riyadh, the largest female-only university in Saudi Arabia.In particular, BLS knowledge was compared according to college and year of study and the effects of prior BLS training on BLS knowledge and attitudes towards training was investigated.

Methods
This prospective, cross-sectional study took place between January and April 2016 and involved all 2,955 students attending the five health colleges (Medicine, Dentistry, Nursing, Pharmacy and Health & Rehabilitation Sciences) at PNU.These colleges share a common preparatory year known as the basic health sciences year.Previous research has indicated average BLS knowledge scores of 38-45% among allied health medical students; as such, the minimum required sample size was calculated to be 614 using a test value of 45% with a 5% margin of error, 95% confidence level (α = 0.05), beta value of 0.20 and 80% power. 6eviously validated questionnaires to assess knowledge of CPR and BLS were updated according to recent American Heart Association guidelines, where appropriate. 9,13,14Attitudes towards BLS were evaluated using another previously validated questionnaire. 3 As such, the final self-administered questionnaire contained 27 questions assessing BLS knowledge and skills (21 multiple choice questions) and attitudes towards BLS (six multiple choice questions).As the majority of courses at PNU are taught in English, the questionnaire was distributed in its original English-language format.The final questionnaire was pilot-tested among a group of 30 female health students which resulted in an overall Cronbach's alpha value of 0.81 (0.76 for the knowledge section and 0.74 for the attitudes section).No changes were made to the questionnaire as a result of the pilot study.Subsequently, the questionnaire was distributed to all female health students at PNU by two research coordinators during class at the end of scheduled lectures.The importance of the study for improving BLS education at PNU was explained verbally during distribution of the questionnaire.The participants who had previously taken part in the pilot study were subsequently included in the main study.
Data were analysed using the Statistical Analysis System software, Version 9.4 (SAS Institute Inc., Cary, North Carolina, USA).Categorical variables were reported as numbers and percentages while continuous variables were expressed as means and standard deviations.Responses to knowledge questions were analysed according to an answer key developed from the original questionnaires; subsequently, the percentage of accurate responses for each multiple choice question was calculated. 9,13,14he overall knowledge score for the entire sample was expressed as the percentage of correct answers out of all 21 knowledge questions.Accordingly, knowledge levels were classified as excellent (90-100%), very good (80-89%), good (70-79%), acceptable (60-69%), poor (50-59%) or very poor (<50%).Associations were calculated using analysis of variance, Fisher's exact, Chi-squared or Tukey's multiple comparison tests, as appropriate.A P value of ≤0.050 was considered statistically significant.
Ethical approval for this study was obtained from the Institutional Review Board of PNU before data collection (IRB #08121504).The study was conducted in accordance with the principles of the Declaration of Helsinki.All of the participants gave informed verbal consent and were assured that completion of the questionnaire was voluntary and anonymous.

Discussion
To the best of the author's knowledge, this is the largest study to evaluate BLS knowledge and attitudes towards training among Saudi women.Unfortunately, although the results of the study indicated that female health students had overall positive attitudes towards BLS training, the majority of the students were severely deficient in BLS knowledge.These findings are in agreement with those of previous research from Saudi Arabia, which have consistently shown poor BLS awareness but favourable attitudes towards BLS training. 4,5,87][8] The lower scores observed in the present sample may be due to the lack of BLS training in the PNU colleges' curricula, even though BLS education is strongly encouraged.In contrast, Alotaibi et al. found that female students achieved significantly higher scores than male students when comparing BLS knowledge levels by gender among Saudi dental students. 8Reddy et al. similarly observed higher mean knowledge scores among female dental students compared to their male counterparts. 15nterestingly, Alotaibi et al. have also shown that Saudi men are more reluctant to perform CPR on a stranger in comparison to women; however, this factor was not evaluated in the present study. 8][18][19][20] Perceived barriers to BLS competency-including a lack of adequate education (i.e.knowledge acquisition) and educational reinforcement (i.e.knowledge retention)-should be addressed in order to improve BLS knowledge and skills among healthcare trainees.In the current study, internal BLS training performed in college resulted in better outcomes than external training, including better knowledge scores and more favourable attitudes towards BLS.Therefore, integrating a BLS training programme into the undergraduate curricula could be beneficial; this recommendation has been previously advocated in order to improve students' resuscitation skills. 16arly exposure to BLS training in college with subsequent refresher courses for reinforcement is essential to improve BLS knowledge acquisition and retention among students. 10,13,21Another proposed recommendation to improve BLS knowledge among Saudi female health students is to simplify BLS training to be more appropriate and cost-effective. 13or example, poorly executed and inefficient chest compressions and rescue breaths prevent effective CPR, whereas high-quality standard CPR produces 25-33% of normal cardiac output and oxygen delivery; as such, competency in these two basic skills is vital. 14,22,23n the present study, only 18.5% of the students knew the correct rate of chest compressions and 21.1% were aware of the recommended chest compression depth.This observation is alarming considering the simple, yet critical, value of chest compression skills. 14Peer-led training may also serve to increase the number of female BLS educators at PNU, which could further disseminate BLS knowledge in both the university itself and the wider community. 24here are several limitations to this study.While this study measured BLS knowledge and attitudes, it did not evaluate actual BLS skills among the students.As many of the participants had not previously received BLS training and the majority had poor knowledge levels, their practical BLS skills are expected to be poor.Further research evaluating students' BLS skills in practice is required but should accompany effective BLS educational programmes.In addition, although the number of participants was large, there was a low response rate from some of the colleges.This may be because the questionnaires were manually distributed after lectures when some of the senior students and interns may have been based in teaching hospitals for their practical training.Consequently, future studies should consider distributing questionnaires by e-mail in order to reach a larger cohort.

Conclusion
The findings from this study suggest that more BLS training is necessary among Saudi female health college students at PNU.Despite having very positive attitudes towards BLS training, many of the students had never received BLS training; moreover, very poor BLS knowledge levels were observed, even amongst the trained students.As students who had received BLS training in college had higher knowledge scores, it is advised that BLS training be incorporated into the university curricula, preferably for first-year students and with refresher courses offered in subsequent years.The author would like to thank Ms Anita Choco and Ms Waad Al-Negaimshi for their invaluable help with data collection during this study.c o n f l i c t o f i n t e r e s t The author declares no conflicts of interest.

f u n d i n g
No funding was received for this study.
a c k n o w l e d g e m e n t s

Application to Patient Care -This
study emphasises the importance of improving current BLS education programmes among health students at a Saudi women's university, particularly as this population is likely to be actively involved in patient care in the future and may need to demonstrate appropriate BLS skills in emergency situations.

Table 1 :
Characteristics of health students attending a women's university in Saudi Arabia (N = 1,349) *A common preparatory year for students in all health colleges.

Table 2 :
Basic life support knowledge levels and scores according to college and year of study among health students attending a women's university in Saudi Arabia (N = 1,349) SD = standard deviation; IQR = interquartile range; HRS = Health & Rehabilitation Sciences; BHS = basic health sciences.*P values are based on an analysis of variance test for continuous scores and Fisher's exact test for categorical scores.† P = 0.491 for comparison among the five groups.‡ P <0.001 for comparison between the five groups.§ A common preparatory year for students in all health colleges.¶ P <0.001 in comparison with the other five groups individually in paired comparisons.\\ P <0.010 in comparison with second-year students.No statistically significant difference was observed between second-and fifth-year students based on Tukey's multiple comparison test (P = 0.626).

Table 3 :
Frequency of correct responses to questionnaire items assessing basic life support knowledge among health students attending a women's university in Saudi Arabia (N = 1,349) If an infant shows symptoms of foreign body aspiration and you have confirmed that they are unable to cry/cough, perform back blows and chest compressions of five cycles each, then open the mouth and remove the foreign body only if it can be seen 536 (39.7)EMS = emergency medical services; CPR = cardiopulmonary resuscitation; BLS = basic life support.

Table 4 :
Frequency and attitudes towards basic life support training among health students attending a women's university in Saudi Arabia (N = 1,349)

Do you think BLS training should be mandatory and, if so, where should it be provided?
*Total dataset for this variable was 1,039 as the question was targeted only at those students who wanted more BLS training.† Total dataset for this variable was 1,076 as the question was targeted only at those students who had not previously received BLS training outside of college.

Table 4 ]
. Students who had previously received BLS training in college had significantly greater BLS knowledge scores compared to those who had received BLS training outside college, those who had received BLS training both in and outside college and those who never received BLS training (41.7 ± 13.0 versus 32.4 ± 10.9, 33.3 ± 12.6 and 32.7 ± 13.1, respectively; P < 0.001).There was no significant difference in knowledge scores between those who had never received BLS training before and those who had received training outside college or both in and outside college (P = 0.856) [Table 5].According to their previous history of BLS training, 98.3% of students with no prior BLS training wanted further BLS training in comparison to 87.9% of the students who had prior BLS training (P <0.001).In addition, students without prior training also favoured earlier BLS training (i.e.training provided in high

Table 5 :
Basic life support knowledge levels and scores according to previous training history among female health students attending a women's university in Saudi Arabia (N = 1,349)

Table 6 :
Attitudes to basic life support training according to previous training history among health students attending a women's university in Saudi Arabia (N = 1,349)

When do you think BLS training should first be provided?
Comparison between no training and both in and outside college training.¶ Comparison between in college training and outside college training.\\ Comparison between in college training and both in and outside college training.**Comparison between no training and any previous training.
*P values are based on Chi-squared or Fisher's exact tests, as appropriate.† Comparison among all four groups.‡ Comparison between no training and in college training.§