Assessment of Knowledge and Attitude of Basic Life Support (BLS) among Schoolteachers in the Jazan Region, Saudi Arabia

Background: Basic life support (BLS) is vital for out-of-hospital cardiac arrest survival. Previous studies suggested that Saudi schoolteachers' BLS (1, 422) = 25.48, p = 0.000]. In general, teachers had positive attitudes towards the importance of BLS and were willing to have future BLS training. Conclusion: The study showed that schoolteachers had positive attitudes towards BLS but lacked BLS knowledge which would affect their skills.


INTRODUCTION
Unintentional or accidental injury represents an international concern as it can lead to disabilities and death [1]. Many disabilities and deaths that occur due to accidental harm are preventable. The American Heart Association (AHA) describes basic life support (BLS) skills as recognition of a variety of life-threatening emergencies by first responders, providing Cardiopulmonary resuscitation (CPR) and choking aids and possessing skills to provide care to those who experience cardiac arrest, respiratory arrest, and airway obstruction [1]. Students in schools can be subjected to the risk of falls, choking, trauma, and many accidents during their school hours [1]. Teachers are considered caretakers of students as they are in the school and are responsible for children's wellbeing and safety at school [2]. Teachers' responsibilities regarding the pupil's health range from giving medications to handling emergencies [3]. The first minutes after an accident are crucial to reducing injury, so the awareness of first aid among teachers could reduce morbidity and mortality of children at school. Nowadays, it is attainable to learn CPR through various sources. However, several studies have shown that many factors, such as administering it incorrectly, making the situation worse, and fear of catching an infection, limit correct CPR practice [2,3]. Studies conducted worldwide reported inadequate BLS skills [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]. Some studies from Saudi Arabia that assessed knowledge and attitudes towards BLS were conducted in secondary schools a few years ago reported insufficient knowledge, lack of training and BLS skills [1,3,7]. Other studies conducted in Saudi Arabia were focused on community health workers, university lecturers and medical students and reported similar findings [11]. Even if there are several studies that assessed the Knowledge and Attitude of BLS among teachers, their findings might not accurately represent the current situation in the Jazan region, where there is still a lack of local data. Therefore, we conducted this study to evaluate the current knowledge and attitude regarding BLS among schoolteachers in the Jazan region.

Study Design and Participants
A cross-sectional study that involved 424 teachers of the Jazan region public primary, intermediate, and secondary schools, Saudi Arabia, was carried out between 14 th October and 26 th December 2021. We excluded retired teachers, those working outside the Jazan region, and pre-school teachers. A minimum sample size (n=422) was calculated with a confidence interval of 95%, margin error not exceeding 5%. A pilot study was conducted to test if the questionnaire's wording was clear and understandable.

Sampling Technique and Study Population
We used a multistage cluster random sampling technique to recruit teachers. The local education directorate is already divided into two districts, Jazan and Sabya. One educational office was selected from each education district using a simple random sampling technique during the first sampling stage. Schools in each education office were stratified into three strata according to the level of the school (primary, intermediate or secondary schools). In the second stage of sampling, two male and two female schools were selected using a systematic sampling technique, making 24 schools. Finally, all teachers from each school were invited to participate in the study.

Study Tools
Data was collected using an online selfadministered Arabic questionnaire previously validated and used in another published study [16]. This questionnaire consisted of four sections; the first section collected data on sociodemographic data and previous training status. The second section included ten questions about knowledge and BLS skills. The third section had eight questions to assess attitudes toward learning and practicing CPR.
Finally, the fourth section included questions about the barriers to performing CPR and previous resuscitation experience.

Statistical Analysis
The data were coded, tabulated, and statistically analyzed using IBM SPSS Statistics for Windows, version 23.0. (Armonk, NY: IBM Corp.). Both descriptive and inferential statistics were used. For the descriptive analysis, results were expressed as numbers and percentages for categorical data and means (± SD and 95% CI) for continuous data. For the knowledge and skills section, the accurate response was given one and the wrong response was given zero. The ten questions were added together to obtain a total knowledge score. A normality test was conducted to determine if the data were normally distributed. Accordingly, a distributed t-test and Analysis of variance (ANOVA) test were used to compare the mean knowledge scale across variables. The accepted level of significance was below 0.05 (P < 0.05).

RESULTS
A total of 424 participants completed the study questionnaires.

DISCUSSION
CPR is one of the most significant factors for reducing death rates due to out-of-hospital cardiac arrest [17]. Therefore, knowledge and skills in CPR are essential for the survival of cardiac arrest victims and should be regarded as a primary educational strategy according to the international resuscitation council [18]. Some countries like Norway adopted BLS as a part of the school curriculum, and CPR training for schoolteachers has been compulsory since 1961 [19]. In Saudi Arabia, however, BLS training  [25] and the findings of other studies conducted in Saudi Arabia [3,12,20]. The limited BLS knowledge in this study was reflected in the frequency of incorrect answers, particularly in BLS sequence and technique. Our findings agree with other studies that found the level of BLS knowledge among Saudi schoolteachers to be 43% in Riyadh and 30% in Al-Madinah [12,20]. This might be due to the lack of BLS training for most participants because we found that only 19.6% of schoolteachers in the Jazan region had been previously trained in BLS.
Moreover, the majority (72.3%) of teachers were trained more than 2 years prior and were not enrolled in any additional courses to improve and update their knowledge and skills. Similar results of poor knowledge and challenges were reported in a study conducted in the United Kingdom (UK) [21]. Most (59.2%) teachers in our study were not aware of the need for training to use AED (59.2%), unlike the study from Denmark by Line Zinckernagel et al., who found that teachers considered AED training to be too complicated to be included in the curriculum and preferred separate training by a professional. However, they reported that teachers lacked skills in using them and were not aware of AED available at their schools [22].
Most teachers enrolled in this study had poor knowledge of chest compression technique. Only 9.4% correctly responded to the question regarding the depth and pace of chest compressions. Previous BLS training was significantly associated with higher knowledge scores (p=0.0001). This aligns with experimental study findings from Iran that indicated higher knowledge after basic BLS training [23]. Though the association of gender with BLS knowledge and skills was not well studied among schoolteachers, we found that the male gender was significantly associated with higher knowledge than the female gender (95% C.I.: 0.19-0.69, p<0.001). The difference might be due to cultural variabilities such as less training for female teachers rather than intrinsic gender differences. Our study also showed that more males (33.7%) than females (13.4%) received BLS training in our sample (P = 0.001). Our findings agree with a study carried out in the United Kingdom that found female participants less likely to get trained in resuscitation and CPR techniques than their male counterparts [24]. The main reason for the lack of BLS training among schoolteachers was not knowing where to take CPR training courses. This is the same reason reported in previous studies in Saudi Arabia [3,20] and Palestine [7]. Therefore, establishing BLS training at schools close to teachers would improve knowledge of BLS among schoolteachers.
Moreover, our study indicated that schoolteachers generally had positive attitudes regarding BLS, as shown by their willingness to undertake more training and their support for making BLS training mandatory for schoolteachers. Similar attitudes were observed in other studies conducted on Saudi teachers [12,20]. In contrast, most teachers in this study opposed making CPR training a requirement to get certified as qualified teachers. The reason might be their perceptions of CPR training as more complicated, too technical and challenging. A similar reason was reported in another study from Denmark [22]. This negative view may be improved by education programs to raise schoolteachers' awareness of the vital role of CPR in saving lives.
Despite being one of the few studies in Saudi Arabia and the first study in Jazan to evaluate the current schoolteachers' knowledge and attitudes toward BLS, the generalization of our findings is limited by the cross-sectional approach and the use of an online questionnaire. Given the practical nature of cross-sectional studies and the time of data collection, which coincided with the COVID-19 pandemic, a longitudinal, interview-based study followed by an interventional study was not possible.

CONCLUSION
The study found that most schoolteachers in the Jazan region had limited knowledge and skills in BLS despite their positive attitudes towards BLS training. Different factors, such as gender, influence these findings, aligning with some previous reports in the country. Previous BLS training was strongly associated with better BLS knowledge and skills. Thus, we recommend that education authorities in Saudi Arabia establish obligatory BLS training and periodic refreshing courses for all schoolteachers. Extensive, longitudinal, interview-based studies are also recommended to further investigate BLS knowledge and skills among schoolteachers to confirm the current findings, raise awareness regarding schoolteachers' knowledge and attitudes toward BLS, and help establish corrective measures.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
Teachers who decided to participate in the study consented by signing online consent forms. All of the teachers were informed of their right not to participate or withdraw from the study at any time. The data's privacy and confidentiality were preserved by ensuring anonymity during data collection, and there was no disclosure of the information data to anyone outside the study.

ETHICAL APPROVAL
The study was approved by the Research Ethics Committee of Jazan University, Saudi Arabia (REC-43/03/035).

DATA AVAILABILITY STATEMENT
The data presented in this study are available on request from the corresponding author.