Evaluation of Public Awareness, Knowledge and Attitudes towards Basic Life Support among Non-Medical, Adult population in Muscat City, Oman: Cross-Sectional Study

OBJECTIVES: This study investigated the level of public awareness, knowledge and attitudes towards BLS among non-medical adult Omanis in Muscat City, Oman and explored the association between knowledge and attitude and the socio-demographic characteristics.


Introduction
Basic life support (BLS) is a level of medical care that is offered to victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital. 1Considering that life-threatening illnesses or injuries may occur at places where there are no medical practitioners or health service providers, it is imperative that laypeople are equipped with all the necessary knowledge and skills to provide BLS.Nevertheless, there is a tendency of people to make assumptions that BLS ought to be performed by qualified medical personnel and this has resulted in some deaths that could have been avoided.Therefore, it is necessary to assess the general public on their knowledge, and awareness about BLS; and their attitude toward BLS so that proper interventions could be performed as appropriate. 2In the Oman population, the annual incidence of OHCA was reported in 2017, and it stated that the annual incidence ranged between 516-780 cases. 3Furthermore, the outcomes and coronary angiography findings of patients following OHCA in Oman indicated that 13% of patients survived and were discharged, although three survivors suffered from permanent hypoxic brain damage. 3Further, the Sultan Qaboos University Hospital in Oman observed that virtually every cardiac arrest patient admitted was brought to the hospital by friends or family relatives without being given cardiopulmonary resuscitation (CPR) first aid.Therefore, the foregoing situation in Oman may be attributed to lack of adequate knowledge, awareness, and skills of the general public in performing BLS.
asking about participant's awareness of BLS.The third part was about participant's knowledge of BLS that has 15 multiple choice questions.This validated part of the questionnaire was adopted from the Author, Dr.Maha Al-Mohaissen, who had developed the original questionnaire and used it in her study, Knowledge and Attitude Toward Basic Life Support Among Health Students at a Saudi Women's University; a cross-sectional study, which was conducted in Suadi Arabia in 2016. 4The questionnaire with its key answers conformed to the latest American Heart Association (AHA) BLS guidelines.The fourth part, Attitude toward BLS, was about participants' attitude toward BLS which was Likert Rating Scale with five levels (1=Strongly disagree, 2=disagree, 3=uncertain, 4=agree, and 5=strongly agree).It was adopted from the author Dr. Anurag Patidar who used it in his study; Attitude of school students towards Basic Life Support in Punjab, India, 2014. 5The questionnaire was modified by consulting with five PhD experts from both the clinical and academic nursing departments, Oman.CVI result was good with an average validity score of 92%.Also, test retest reliability coefficient of the attitude scale was calculated as r=0.784.
Both Forward-Backward translation with the validity of the accuracy of wording were done.
The tool was tested on 20 eligible subjects prior to data collection.A website-based questionnaire tool was designed and easily accessed by the participants.

Analysis
The SPSS program was used to analyze the data.A qualified statistician and data manager were employed to manage and analyze these data appropriately.Categorical variables were summarized as counts and percentages, whereas continuous variables, including knowledge and attitude, were summarized as means and corresponding standard deviations, or medians and interquartile range (IQR).Moreover, knowledge total scores and attitude total scores were tested for normality using the Shapiro-Wilk test and their distributions were compared between the categories of socio-demographic characteristics.Thus, the student t-test or analysis of variance (ANOVA) was performed to compare the distributions when data were normally distributed; otherwise the Mann Whitney U test or the Kruskal Wallis H test was used.Furthermore, the difference between proportions within a categorical variable was tested using the homogeneity test of proportions, while the differences in the distributions of knowledge and attitude between the categories of a socio-demographic characteristic were assessed using independent samples tests and, where necessary, the post hoc analysis was performed to detect the significance of the differences between paired comparisons, for which the Bonferroni correction was used to adjust the P values.All the statistical tests were twotailed and the significance level was set at the 5%.

Patient/Public Involvement
Patients and public were not invited to comment on the study design, outcomes or interpret the results or writing or editing the document.

Distribution of attitude total scores
Attitude total scores of the participants weren't normally distributed (W (426) =0.976, P<0.001), with minimum attitude total score of 30 out of 65, maximum attitude total score of 65 out of 65, median attitude total score of 55 out of 65 (IQR: 51 -58), and mean ± SD attitude total score of 54.5 ± 5.5.Also, item scores, for each attitude item were not normally distributed (W (426) = 0.976, P<0.001).Therefore, majority of the participants had positive attitude towards BLS (Table 4).

Distribution of knowledge and attitude across socio-demographic variables
Considering that both BLS knowledge and attitude total scores were either not normally distributed, or measured on a smaller number of subjects in the respective categories of the socio-demographic variables, non-parametric tests were used to assess the significance of any difference in distributions across the foregoing socio-demographic variable categories.
Therefore, the independent samples Kruskal Wallis H test was used to compare the distributions among more than two categories, whereas the Mann Whitney U test was used to compare the distributions between two categories.The results indicated that, although the participants were generally poor in knowledge about BLS, male participants were more knowledgeable than female participants.In addition, those with Doctoral level of education were more knowledgeable than those who had other levels of education.Besides, those with occupation in Government and Private sector were more knowledgeable than housewives and students (Tables 5).However, the level of attitude was the same across the categories of the socio-demographic variables (Table 6).Besides, there was a significant weak positive linear relationship between the knowledge total scores and the attitude total scores (Pearson correlation: r = 0.116, P value = 0.017).chocking and proper interventions in this regard would be cost efficient among this study population.In relation to helping an adult unresponsive victim who had been submerged in fresh water then was just removed from it and was showing signs of spontaneous breathing, but unresponsive, a larger proportion of the participants (93.4%) responded incorrectly on what they would do first in order to help such an adult person.According to the World Health Organization (WHO), drowning is a serious but neglected public health threat that claims the lives of approximately 372, 000 people per year worldwide.

Association between public knowledge toward BLS and sociodemographic variables
Although the participants were generally poor in knowledge about BLS, this study found that there was an association between some socio-demographic variables and knowledge levels toward BLS specifically, gender, level of education and occupation.For example, male were more knowledgeable than female.Also, Doctoral level holders were more knowledgeable than those other levels of education; whereas those with occupation in Government and Private sectors were more knowledgeable than housewives and students.
The finding of male was more knowledgeable than female is consistent with the findings of some previous study. 13Moreover, it is in agreement with the recent findings that the Omani female population is much lagging behind in literate life expectancy than the Omani male population. 14Therefore, this finding underscores the need to reduce the gap in BLS knowledge between male and female so that both genders could confidently and skillfully provide BLS services.
Furthermore, just like in this study, several studies have demonstrated that BLS knowledge has been poor among the levels of education, such as primary, secondary, and college.
15 16 17 Although the doctoral group was associated with better BLS knowledge than the preceding education level groups, their knowledge was still inadequate.
Therefore, this outcome suggests that introducing BLS training in the school's curriculum at all levels would pay great dividends for the prevention of deaths resulting from any emergency life threatening events.
Also, housewives and students demonstrated to have poorer knowledge in BLS than private and government workers is consistent with the findings of other similar studies.

Public attitude
It was found that all participants had positive attitude toward BLS.This was an encouraging result, which suggests that many Non-medical people would be willing to attend training in BLS, should there be an initiative to train them.
This finding is consistent with some previous prospective study on senior undergraduate student-teachers enrolled at South African university, which found that the studentteachers surveyed displayed poor knowledge and perceptions but positive attitudes with regards to practice of CPR and BLS, and this suggested that formal CPR training was supposed to be part of the curriculum for teachers. 19The BLS training increases laypersons' confidence and willingness to perform bystander CPR on a stranger.In this study, despite socio-demographic characteristics being associated with the level of knowledge, they were not associated with the level of attitude.This is not a surprising result considering that all the participants had virtually same level of attitude toward BLS, which is a great factor in making BLS training effective among study population.

Limitation of the study
Convenience sampling method was used, which is susceptible to selection bias.However, the large sample size might have minimized the possibility of selection bias.Also, crosssectional design could not establish the causal effect of socio-demographic characteristics on the level of knowledge.Therefore, prospective studies are warranted to confirm the observed associations between socio-demographic characteristics and the level of knowledge.Finally, when performing group comparisons of knowledge and attitude, some groups such as the 48+ years old, the divorced, the primary and doctoral levels of education and the retired groups, had far much smaller subject numbers, which might have compromised the statistical power.

Implication
This study suggested that there is a huge gap between awareness of BLS and having skills in BLS.Also, the level of knowledge about BLS was very low among the study population but there were still differences in the level of knowledge with respect to the socio-demographic characteristics.In contrast, this study proved that all participants had a positive attitude toward BLS.
Finally, considering the increasing rate of illnesses and injuries that require BLS measures in Oman, policymakers in Oman should advocate mandatory training in BLS for all nonmedical population in the country.Furthermore, incorporating BLS teaching in school curriculum would be helpful for ensuring that many students acquire the necessary knowledge and skills to provide BLS services when needed.Also, learning from and using other people's experiences in other population as regards BLS training would help increase the knowledge and awareness of BLS, hence increasing the chances that more lives would be saved.

4 18 Besides
, the housewives need not be left out when conducting interventions to improve BLS knowledge among the laypeople of Muscat in Oman.The housewives stay with children at home most of their time and if they do not have adequate skills to provide first aid to fatal accidents involving the kids, then the prevalence of poor outcomes in relation to such type of accidents would increase.Therefore, BLS training for housewives is warranted just as for the other categories of workers.

Table 1 :
Sample Characteristics Participant's awarenessLarge proportion (62.0%) were already aware about cardio-pulmonary resuscitation (CPR), but had never received any CPR training (70.9%).Nevertheless, majority of those who indicated that they had received CPR training (29.1%) specified that they had received the training from Television-Internet-Media (33.1%), at a course given by the trainers of the Ministry of Health (21.0%),CPR education institutions (12.9%) and at school (12.1%).Moreover, those who indicated that they had not received CPR training expressed that they intend to attend CPR training in the future (84.8%).(Table2)

Table 2 :
Public Awareness About BLS that the collapsed person was unconscious, not breathing and had no pulse [222 (52.1%)]; what number to call for emergency medical services [328 (77.0%)]; and what to do first upon witnessing an infant choking while playing with a toy but the infant was unable to cry or cough [241 (56.6%)] (Table3).

Table 3 :
Public knowledge about BLS If You confirm that the collapsed person is unconscious, not breathing and has no pulse.What would you do next?(Note: You are alone) What is the correct ratio of Cardio-Pulmonary-Resuscitation (Compression: Ventilation Ratio) for an adult when there is a single rescuer?

Table 5 :
Distribution of BLS Knowledge Across the Socio-Demographic Variables Kruskal Wallis H test; and U Mann Whitney U test.Kruskal Wallis H test; and U Mann Whitney U test.