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Knowledge and Attitudes on First aid among Advanced Level Students in Gampaha Educational Zone, Sri Lanka.

Background First aid is the initial care given in an emergency, to protect life and to prevent worsening of the condition of the victims, until they are undertaken by a professional medical person. It is essential to know basic first aid as a responsible person in society. The current study was conducted to assess the knowledge, attitudes and practices on first aid among advanced level students in government schools in Gampaha educational zone. A descriptive cross-sectional study was conducted among 510 grade 12 students in five randomly selected schools. A pre-tested self-administered questionnaire consisting of25 multiple choice questions on knowledge and 10 statements formed as a Likert scale to assess attitudes. Chi-square test was used to assess the associations and a p-value <0.05 was considered as significant. mainly focused on the assessment of the theory knowledge.


Background
First aid is the immediate care provided to a victim of injury or sudden illnessin emergencies until they are undertaken by a professional medical person [1]. The person providing first aidshould be able to assess the injured as soon as possible and give basic first aid correctly and then contact the proper medical facilities.
In 1990, there weremore than 350millionnew cases of injuries recorded globally and it hasincreased to 520 million new cases by2017 [2]. Even though injuries are considered as an important cause of health lossworldwide, the mortality rate has declined by 2017from 1079 to 738 per 100 000 individuals [2]. In 2013,973 million peoplewere subjected to injuries which required medical attention [2].Most significant causes included car crashes (29%), selfharm(17.6%), falls (11.6%) and violence (8.5%). However, out of the total cases,only around 6% required hospital admission. Out of those cases, the most common reason (38.5%) for admission was having fractures [2].
Traumatic injuries are the main cause of hospitalization over thelast ten years in Sri Lanka and more than 1 million people werehospitalized in 2016 due to injuries. It was ranked number 10 in terms of mortality with 1675 hospital deaths being reported in 2016 [3].
Acommunity survey on injury occurrence among residents in a semi-urban area showed that the incidence of injuries among all age groups was 17.7 per 1000 population over six months.
The common injuries were falling from a height, road accidents, animal bites, sports injuries, cuts andabrasions, poisoning, and burns [4]. When considering school-based injuries or accidents, the majority occur during "free periods", within the classroom and are minor injuries [5].
Knowledge on first aid is importantfor everyone [5].The person that will use first aid must know its rules and practices properly to achieve optimum results. A study conductedatMonsul University, Iraq on first aid knowledgeusing a"true/false" questionnaireamong124 students from the school of science and school of education revealed that the overall knowledge is 46%. The majority (n=57, 96%) of the students believedthat they need to have proper training on first aid activities [6]. A similar study done in Turkey among 134students of the Vocational School of Health Services at Kirklareli University revealed that65.7% (n=88) of students had not received any formal first aid training. Of the sample, 65.7% (n=88) of students had not received any first aid knowledge before. However, 82.8% (110) knew the pulse rate of an adult while 56.7%(75) knew the respiratory rate of an adult. About one-fourth of the sample (n=35, 26.1%) stated that gasoline, bleaching liquid or similar substances should not be used to induce vomiting if a patient has ingested poison [7].Lack of local research makes it imperative to conduct large-scale research to assess knowledge, attitudes and practices on first aid to develop evidence-based interventions.

Study Aim:
The current study was conducted to assess knowledge, attitudes and practiceson first aid among advanced level students in government schools in Gampaha educational zone.

Study setting:
The study was conducted in Government schools located in Gampaha educational zone. According to the national school census 2016preliminary report, total government schools in Gampaha educational zone is48, out of which only 14 schools had classes up to advanced level.

Study participants
The study population wasgrade 12 and 13 students of both sexes(age range = 18-19 years)in government schools inGampaha educational zone.

Sample size calculation
Sample size determination was through the following equation [8] ; n = Z 2 P(1-P) /d 2 Z= Critical value of specified confidence level, for this study the confidence level set at 95% and thus the critical value is 1.96. As there are no studies done in Sri Lanka to assess the knowledge, attitudes or practice levels regarding the first aid at the community level,the prevalence of poor knowledge was considered as 50% to maximize the sample size.
Applying the values to the equation; n= (1.96 × 1.96 × 50 × 50) / 5 × 5 = 384 A non-response rate of 40% was considered. Therefore, the final sample size was increased to 540. The sample size achieved was 510.

Sampling techniques
The list of schools with advanced level students (14) was obtained from the western provincial education department and rearranged according to the alphabetical order. Based on the logistical feasibility it was decided to select five (5) schools from the prepared sampling frame randomly. Accordingly, five (5) schools were selected based on computer-generated random numbers. The total sample size was divided equally among the selected schools.

Study instrument
A self-administered questionnaire was used to collect data. It was developed in the English language (Annexure 1) and then translated to Sinhala and Tamil languages. The face and content validity wasassessed by a panel of experts. The questionnaire contain the following parts;socio-demographic details, knowledge and attitudes on first aid. Pre-testingof the questionnaire was done among A/L students in a school which was not selected for the main study and some adjustments were made in the wording of the questionnaire. The data collection was done by the principal investigator. After explaining the details of the study, informed written consent was obtained.

Statistical analysis
Primary data were entered to Microsoft Excel 2007 and exported to Statistical Package of Social Science for windows version 21 (SPSS Inc., Chicago, IL, USA). The level of knowledgeand attitudes were considered as dependent variables. Numerical variables were described using mean and standard deviation. Categorical variables were expressed as percentages. The bivariateanalysis was done using chi-square test. To calculate a total first aid knowledge score, one (1) mark was given to each correct answer and zero (0) markswere given for each wrong answer in the knowledge section. The totalscores were then converted to percentages and were graded according to a scale where a score of≤24 was considered as "Inadequate knowledge", scores between 25 to 49 was classified as"Moderate knowledge", scores between 50 and74 was considered as "Good knowledge" and scores≥75 were grouped as "Excellent knowledge". A p-value ≤ 0.05 wasconsidered as significant.

Administrative and Ethical clearance
Ethical clearance was obtained from National Institute of Health Science, Kalutara, Sri Lanka (ERC clearance No: NIHS/REC/17/05R). The information sheet was provided with all necessary information to the participants thus allowing asking questions as well. Informed written consent was obtained before the administration of the questionnaire. Administrative clearance was obtained from the Director, Department of Education -Western Province and principals of respective schools selected.

Socio-demographic information of students
The response rate was 94.4% and the final sample size achieved was 510.In the study sample, 185(36.3%) were males and all students were aged between 17(26.7%) to 18(74.1%)(Table2). More than a quarter of the students (n= 144, 28.3%), were studying in biology streamwhile 122(23.9%) were in commerce stream, 144 (28.3%) were in mathematics stream and the rest were studying in the artsstream. Nearly half of the students (n=254, 49.8%) followed the health science subject during their ordinary level studies (O/L) and only 16.9% (n=86) of the students were previously trained on first aid ( Table 2). Table 2:Socio-demographic and education-related information of the respondents

Knowledge on first aid
The mean knowledge score was57.4 (SD=13.5) where the maximum was 89 and the minimum was 16 ( Figure 1). According to the first aid knowledge grading, 1% (n=5)were categorized as having "inadequate knowledge", 30.6% (n=156) had "moderate knowledge", 61.4% (n=313) were having "good knowledge" and 7.1% (n=36) were categorized as having "excellent knowledge" ( Table 3).The majority (n=486, 95.3%) wereable to define "first aid" and 56.9% (n=290) knew first steps in managing a first aid situation. When considering the first aid knowledge for given emergencies, the majority was correct infollowing situations; 62.9%(n=321) knew the correct first aid for deep bleeding cut on the palm, 81.4%(n=415) were able to provide first aid for broken glass piece sticking in the leg, 89.2% (n=455) students were aware of first aid steps for electric shocks, 88.2 % (n=450) knew correct first aid for snake bites before hospitalization and 87.6% (n=447) knew how to check for breathing in a person. In contrast, the majority was wrong in the following situations; 66.1%(n=337) were not aware of first aid to stop nasal bleeding, 74.3% (n=379) were unable to give the correct answer for first aid in sprains/strains, 72.4% (n=369) students were not aware of thecorrect first aid procedure for accidental ingestion of poisons and 82.7%(n=422) were not aware of correct CPR ratio. In following situations nearly half of the population were having the awareness; the first step in managing an emergency, first-aid for bone fracture in leg, first aid procedure for a choking person, first aid for burn injuries, first aid for seizures, steps in managing a heart attack and importance of CPR. More than three fourth of the sample(n=388, 76.1%) knew the shortcode (1990) number to contact "Suwasariya" free ambulance service (Table 4).

Attitudeson first aid
The overall attitudesregardingfirst aid were positive and most of the students (n=504,98.8%) believed it is essential to have first aid knowledge. Their willingness to give first aid inthe following emergencies was high; heart attacks, drowning, severe bleeding, and road traffic accidents ( Table 5). The common reasons to hesitate to provide first aid assistance for a victim of road traffic accident werelack of knowledge in first aid(n=202 39.6%), legal consequences (n=176,34.5%), and fear of road traffic accidents (n=44,8.6%).

Correlation of first aid knowledge with attitudes
There was only a slight correlation (r=0.134, p=0.003) between knowledge and attitudes indicating almost no relationship between knowledge and attitudes on first aid.

Factors associated with knowledge
Astatistically significant association was seenbetween first aid knowledge and advanced level stream(χ 2 =15.26, p<0.001; Table 6) where knowledge of students studying in the biology stream was higher than others. The students who had followed health science duringtheir O/L studies had a significantly higher knowledge score when compared to others (χ 2 =12.4,p=0.006; Table 6). However, previous training on first aid had no significant relationship with the first aid knowledge (χ 2 =7.2, p=0.064; Table 6). Nostatistical significance was found between first aid knowledge and gender (χ 2 =3.8, p=0.284; Table 6).

DISCUSSION
The study shows overall fair knowledge and positive attitudes towards first aid among advanced level students in Gampaha educational zone. More than half of the students were having a good knowledge while 7.1% were excellent in their first-aid knowledge. Incontrast, a study done in Dehradun, India among grade 9 to 12 students showedthat 33.3% had only a partial knowledge while only 23.1% had adequate knowledge on first aid [9]. Another study conducted in Pondicherry, India among grade 9 students shows that the majority (76.7%) have inadequate knowledge with only 23.3% having moderate knowledge on first aid [10]. A study in Telugana, India among undergraduate students showedthat only 38% had inadequate knowledge [11].
In some specific first aid situations, students showed poor knowledge, such as nasal bleeding, sprain/strains, first aid for ingestion of poisons and correct CPR ratio.These observations were inconsistent with Semwal et al., where it shows that nearly 99% of the students don"t know first aid for nasal bleeding and sprain/strains [9]. In this study for the situation of accidental ingestion of poisons; 42.4% selected the option of "encourage the person to vomit" and 29.6% selected the "giving coconut milk" option. Both statements are wrong first aid measures. In Sri Lankan rural society, giving coconut milk for the cases of oral ingestion of poison is very popular as revealedin a study done in Sri Lanka about plant and kerosene oil poisoning among children, where 21.7% parents have practised forceful ingestion of coconut milk as a first-aid measure [12]. This clearly shows that some Sri Lankans still have a misconception regarding first-aid practices which could even lead to fatal outcomes [13]. In the above study,only 17.3% of the students knew the correct CPR ratio. In a similar study done in Sri Lanka by Priyangika et al., in 2015 among senior school prefects in Galle education zone, only 26% of students knew the correct CPR ratio and those who knew the correct ratio waspreviously trained on first aid. The main reason for poor knowledge recorded in the current study isbecausethe majority of the students (83.1%) had not received any formal training on first aid. A study done in Turkey by Metin and Mutlu in 2010 among university students shows that 53% were aware of the correct CPR ratio which is a comparatively high figure.
In the present study the overall attitudes towards first aid were positive (77.1%).A similar pattern was seen in a study done in New Zealand [14]. In this study, 95% of the students believed it is essential to have first aid knowledge with them however the knowledge and the attitudes were not significantly correlated (r =0.134). In another study done in Iraq by Makhlef, 2013 among university students, 96% of the respondents stated it"s necessary to learn first aid [6]. Students in the current studyshoweda high willingness to provide first aid assistance for emergencies. A similar scenario is seen in other studies too [5] [15].
However,in certain instances, people are hesitant to provide first aid assistance, for instance, road traffic accidents. The reasons for such hesitations were lack of knowledge in first aid (39.6%) and potential, legal consequences (34.5%). A study done in India by Patidar and Sharma in 2014among school students on basic life support further illustrates thefear for legal actionsleading to hesitancy in becoming a first aid provider. [16] Similar findings are reported in a study done in North Carolina among high school students, where legal issues and fear of infections are the main reasons for not intervening to provide first aid [17].
The evidence from this study indicates that a student"seducational background influencestheir first aid knowledge with those studying in biology stream for the advanced level examinations and students who have studied health science during their O/Ls having a better in first aid knowledge. This is because first aid knowledge is related to the health and life sciences fields. However, previous training in first aid did not influence their first aid knowledge. Similarly, this is noted in a nationwide survey conducted in Norway where most of the population were trained in first aid, but their theoretical first aid knowledge was poor than expected [15]. Therefore merely conducting training programmes on first aid is inadequate to improve and maintain the level of knowledge in the long run. A pilot study done in Norway suggests first aid education in preschools has a better outcome when the application of basic first aid for given situations is considered [18]. Therefore the addition of first aid education as a practical subject for the school curriculum for all grades will lead to better outcomes in terms of first aid knowledge among school students.

CONCLUSION AND RECOMMENDATION
The majority (61.4%) of the students had "good" knowledge on first aid. Astatistically significant association was seen between first aid knowledge and advanced level stream where knowledge of students studying in the biology stream was higher than others. The students who had followed health science during their O/L studies had a significantly higher knowledge score when compared to others. A majority showed positive attitudes towards providing first aid assistance in emergencies and their high willingness is observed.
It is recommended to add first aid as a part of the school curriculum and improve the standard of the all existing first aid training programs in the country. Further studies should be undertaken to assess the practical skills of students, as the current study mainly focused on the assessment of the theory knowledge.     Figure 1: Distribution of the first aid knowledge scores among students.