2Department of Biochemistry, 1College of Medicine, Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia *Corresponding Author’s e-mail: aaalshuwayrikh@gmail.com حجم معرفة وتوجهات طالب الطب يف جامعة اإلمام حممد بن سعود اإلسالمية حنو اإلسعافات األولية، الرياض، اململكة العربية السعودية عبدالرحمن ال�شويرخ، عبدالرحمن اجلذيلي، فار�س الع�شيمي، اأ�شامة ال�شايع، عبداهلل الأ�شمري، حممد املخ�شوب، �شالح اخلنيزان، �شالح الدين خان abstract: Objectives: This study aimed to evaluate knowledge and attitudes towards first aid (FA) measures among medical students at the Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia. Methods: This cross- sectional study was conducted between September and December 2016 among 600 medical students in different academic years at Al-Imam Mohammad Ibn Saud Islamic University. Knowledge and attitudes towards FA measures were evaluated using a modified version of a previously validated questionnaire. Data were compared between students with previous FA training and those without previous FA training. Results: A total of 259 medical students were included (response rate: 43%). Of these, 43% had previously received FA training and 63% had witnessed an emergency first-hand. Mean theoretical (5.93 ± 2.50 versus 4.49 ± 2.08; P <0.001) and practical (4.29 ± 2.62 versus 2.90 ± 2.17; P <0.001) knowledge scores were significantly higher among students with previous FA training compared to those without training; however, there was no significant difference in mean attitude score (5.60 ± 1.66 versus 5.39 ± 1.66; P = 0.329). Conclusion: The medical students, particularly those without previous FA training, demonstrated weak levels of FA knowledge. Such findings necessitate the inclusion of FA training in medical curricula in Saudi Arabia. Keywords: First Aid; Emergency Treatment; Medical Education; Knowledge; Attitudes; Saudi Arabia. امللخ�ص: الهدف: تهدف الدرا�شة لتقييم معرفة وتوجهات الإ�شعافات الأولية بني طالب الطب يف جامعة الإمام حممد بن �شعود الإ�شالمية، الريا�س، اململكة العربية ال�شعودية. الطريقة: هذه درا�شة مقطعية اأجريت بني 600 طالب طب من خمتلف ال�شنوات يف جامعة الإمام حممد بن �شعود الإ�شالمية من �شيبتمرب اإىل دي�شمرب من عام 2016. مت تقييم حجم معرفة وتوجهات عينة من طالب الطب نحو الإ�شعافات الأولية با�شتخدام ا�شتبيان مت التحقق منه م�شبقا مع اإ�شافة بع�س الأ�شئلة. متت مقارنة البيانات بني الطالب الذين تدربوا يف الإ�شعافات الأولية تدريب لديهم الطالب من الإجابة: 43%(. 43% طب )معدل طالب جمموعه 259 ما درا�شة مت م�شبقا. النتائج: يتدربوا مل الذين والطالب مقابل 5.93 ± 2.50( النظرية املعرفة متو�شط الأولية. الإ�شعافات عمل ت�شتدعي طارئة حالة �شاهدوا 63% و الأولية لالإ�شعافات م�شبق 2.08 ± 4.49؛ P >0.001( واملعرفة التطبيقية )2.62 ± 4.29 مقابل 2.17 ± 2.90؛ P >0.001( كان اأعلى ب�شكل وا�شح لدى الطالب الذين تدربوا م�شبقا على الإ�شعافات الأولية مقارنة بالطالب الذين مل يكن لديهم تدريب م�شبق. على النقي�س ل يوجد اختالف كبري بني الطالب املتدربني وغري املتدربني يف توجهاتهم نحو الإ�شعافات الأولية )1.66 ± 5.60 مقابل 1.66 ± 5.39؛ P = 0.329(. اخلال�صة: هناك �شعف املناهج يف الأولية الإ�شعافات مادة اإدخال �رصورة على يدل مما الأولية. الإ�شعافات معرفة يف درا�شتهم متت الذين الطب طالب لدى الطبية. الكلمات املفتاحية: الإ�شعافات الأولية؛ معاجة طارئة؛ التعليم الطبي؛ التوجهات؛ املمار�شات؛ اململكة ال�شعودية. Knowledge and Attitudes Towards First Aid Measures Among Medical Students at Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia *Abdulrahman Alshuwayrikh,1 Abdulrahman Aljethaily,1 Faris Alosaimi,1 Osama Alshaya,1 Abdullah Alasmari,1 Mohammed Al-Makhdob,1 Saleh Alkhonezan,1 Salahuddin Khan2 clinical & basic research Sultan Qaboos University Med J, November 2018, Vol. 18, Iss. 4, pp. e507–512, Epub. 28 Mar 19 Submitted 1 May 18 Revision Req. 6 Jun 18; Revision Recd. 4 Jul 18 Accepted 5 Aug 18 Advances in Knowledge - The current study found that medical students had low levels of knowledge of first aid (FA) measures, even among those who had previously received FA training. - However, there were significantly higher levels of FA knowledge among medical students who had previously received FA training ; this finding supports the inclusion of FA training within the medical curriculum. Application to Patient Care - Proper FA interventions can reduce patient mortality and morbidity. Enhancing FA knowledge among medical students would enable such students to more competently handle emergency situations, thus indirectly affecting medical care. doi: 10.18295/squmj.2018.18.04.013 Knowledge and Attitudes Towards First Aid Measures Among Medical Students at Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia e508 | SQU Medical Journal, November 2018, Volume 18, Issue 4 First aid (fa) is defined as the initial care applied after an injury or acute illness.1 The goal of FA is to preserve life and prevent the patient’s condition from deteriorating until professional healthcare becomes available.2 Any person can begin FA measures in an emergency situation with minimal or no medical equipment needed.1 In particular, healthcare providers have a duty to initiate FA measures in such situations in order to reduce patient suffering and the risk of disability and early death, especially as bystanders often expect such individuals to take appropriate action.2–4 Thus, it is critical that medical students are properly educated in FA and basic life support (BLS) measures, particularly during the early phases of their studies.3 It is recommended that FA training courses be included in the curricula of medical schools and colleges.2–4 Unfortunately, FA training is often neglected in medical curricula.2,5 Several studies have reported dis- appointing results regarding levels of FA readiness among medical students and trainees.2,3,5,6 Tan et al. found that more than 70% of junior doctors lacked FA knowledge and practice.2 In a study from the Netherlands, only 38% of participants met required guidelines regarding FA and BLS knowledge.3 A study from India found that only 13.8% of medical students had good knowledge of FA.5 A previous Saudi Arabian study showed that medical students had poor familiarity with BLS, particularly car- diopulmonary resuscitation (CPR), with 67.36% scoring <50%.6 In the United Arab Emirates, Das et al. reported that a FA training programme for first-year medical students enhanced BLS and FA knowledge and practical skills.7 Similarly, a Turkish study showed the efficacy of such programmes, with FA and BLS training rendering medical students capable of themselves training other students.8 To the best of the authors’ knowledge, no study has yet been published comparing knowledge levels and attitudes between medical students with and without prior FA training in Saudi Arabia. The current study aimed to assess knowledge and attitudes towards FA among medical students at the Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia, particularly with respect to how previous FA training influences students’ knowledge and attitudes towards FA. Currently, a BLS certificate is required for clinical year students in the College of Medicine at Al- Imam Mohammad Ibn Saud Islamic University. This certificate is acquired through a one-day course that is provided by external entities, with the course focusing mainly on CPR. Methods This cross-sectional study was conducted at the College of Medicine of the Al-Imam Mohammad Ibn Saud Islamic University from September to December 2016. A convenience sample of preclinical (from preparatory until third year) and clinical (fourth year and above) medical students was recruited. The required sample size was calculated to be 234 out of a total of 600 potential participants, assuming that the knowledge and attitudes towards FA among medical students would be 50%, with a 95% confidence interval and a margin of error of 5%. A modified version of a previously validated quest- ionnaire was used to assess FA knowledge and attitudes.8 The final English-language questionnaire comprised 41 items, including questions about demographic char- acteristics (nine items), theoretical FA knowledge (11 items), practical FA knowledge (10 items) and atti- tudes towards FA (11 items). The questionnaire assessed various emergency situations and FA approaches, incl- uding CPR, bleeding, burns and bone fractures. The theoretical knowledge section consisted of direct quest- ions, while the practical knowledge items were case- based. Most of the questions were reproduced with permission from Khan et al.8 However, some new quest- ions were added based on a review of the literature.9 Most of the questions were closed-ended multiple choice questions with 3–4 distractors, with some yes/no quest- ions. All of the questions had only one correct answer. The entire questionnaire took between 10–20 minutes to complete. The modified questionnaire was piloted in a group of 52 random students from various academic years. Based on the findings of the pilot study, the questions were edited for clarity and the final version of the quest- ionnaire was validated. Subsequently, the final quest- ionnaire was distributed to 600 medical students in all academic years in the College of Medicine. Both elect- ronic and paper versions of the questionnaire were disseminated to enhance the response rate. The paper version was distributed to all students who were phys- ically in attendance at the College of Medicine at the time of distribution. An Excel spreadsheet, Version 2016 (Microsoft, Redmond, Washington, USA) was used for data entry and the Statistical Package for the Social Sciences (SPSS), Version 19.0 (IBM Corp., Armonk, New York, USA) was used for statistical analysis. Data entry was verified by two researchers to ensure consistency and accuracy. A Chi-squared test was used to determine associations between sociodemographic variables and Abdulrahman Alshuwayrikh, Abdulrahman Aljethaily, Faris Alosaimi, Osama Alshaya, Abdullah Alasmari, Mohammed Al-Makdob, Saleh Alkhonezan and Salahuddin Khan Clinical and Basic Research | e509 knowledge and attitude scores. A student’s t-test was utilised to determine significant differences in mean knowledge and attitude scores between students with and without prior FA training. A P value of <0.050 was deemed statistically significant. This study received ethical approval from the Ethical Committee of the College of Medicine at Al- Imam Mohammad Ibn Saud Islamic University (#0010 7/03/2016-12). Informed consent was granted by all students who completed the electronic version of the questionnaire during completion of the online form. Those who filled in the paper version of the questionnaire gave verbal consent in addition to signed written consent. Results A total of 259 medical students participated in the study (response rate: 43%). Of these, 83 (32%) completed the electronic version and 176 (68%) completed the paper version of the questionnaire. Most participants (79%) were in their pre-clinical years and only 21% were in their Table 1: Emergencies witnessed by medical students at Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia (N = 259) Type of emergency witnessed n (%)* Total Students with prior FA training (n = 112) Students without prior FA training (n = 147) None 96 (37) 43 (38) 53 (36) Burns 76 (29) 32 (29) 44 (30) Fractures/ dislocations 65 (25) 34 (30) 31 (21) Choking 50 (19) 27 (24) 23 (16) Drowning 34 (13) 16 (14) 18 (12) Heart attack 18 (7) 12 (11) 6 (4) Seizure 16 (6) 9 (8) 7 (5) Heat stroke 10 (4) 7 (6) 3 (2) FA = first aid. *Percentages do not add up to 100% as the students could select more than one option. Figure 1: Sources of first aid knowledge among medical students at Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia (N = 259). *Percentages do not add up to 100% as the students could select more than one option. Figure 2: Opinions on the most appropriate time to include first aid training in the medical curriculum among medical students at Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia (N = 259). *Percentages do not add up to 100% as the students could select more than one option. Knowledge and Attitudes Towards First Aid Measures Among Medical Students at Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia e510 | SQU Medical Journal, November 2018, Volume 18, Issue 4 clinical years. A total of 112 (43%) students had had prev- ious FA training, while the remaining 147 (57%) had not. The most frequently witnessed emergencies were burns (29%), fractures/dislocations (25%) and choking (19%). Those with prior FA training had less frequently witnessed emergencies compared to those without training (62% versus 64%) [Table 1]. Students had acquired FA-related knowledge from various sources, the most common being formal training (39%), the Internet/computer software (38%), television (28%) and teachers (28%) [Figure 1]. Most of the students (43–50%) believed that FA training and education should be incorporated into the curriculum during the first two years of their degree programme [Figure 2]. Overall, the mean attitude score was higher than the theoretical and practical knowledge scores (5.47 ± 1.66 versus 5.10 ± 2.36 and 3.51 ± 2.47, respectively). The overall mean combined knowledge and attitude score was significantly associated with prior FA training (15.81 ± 5.64 versus 12.78 ± 4.63; P <0.001). In addition, the mean scores for both theoretical (5.93 ± 2.50 versus 4.49 ± 2.08; P <0.001) and practical (4.29 ± 2.62 versus 2.90 ± 2.17; P <0.001) knowledge questions were signif- icantly higher among students with prior FA training compared to those without. However, there was no signif- icant difference in mean attitude scores between the two groups (5.60 ± 1.66 versus 5.39 ± 1.66; P = 0.329) [Table 2]. The frequency of correct or positive responses to knowledge and attitude items is shown in Table 3. In terms of theoretical knowledge, the rate of correct responses ranged from 34–86%. Less than half of the students (34%) knew the correct ratio of chest compressions to rescue breaths when performing CPR on an adult patient. There was a significant difference in the frequency of correct responses to this item among FA-trained and untrained Table 2: Mean first aid-related knowledge and attitudes scores among medical students at Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia (N = 259) Variable Mean score ± SD P value* Total Students with prior FA training (n = 112) Students without prior FA training (n = 147) Theoretical knowledge 5.10 ± 2.36 5.93 ± 2.50 4.49 ± 2.08 <0.001 Practical knowledge 3.51 ± 2.47 4.29 ± 2.62 2.90 ± 2.17 <0.001 Attitude 5.47 ± 1.66 5.60 ± 1.66 5.39 ± 1.66 0.329 Total 14.08 ± 5.28 15.81 ± 5.64 12.78 ± 4.63 <0.001 SD = standard deviation; FA = first aid. *Using a student’s t-test. Table 3: Correct/positive responses to first aid-related knowledge and attitude questionnaire items among medical students at Al- Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia (N = 259) Item Correct/positive responses, n (%) P value* Total Students with FA training (n = 112) Students without FA training (n = 147) Theoretical knowledge What does CPR stand for? 194 (75) 90 (80) 104 (71) 0.105 Which of the following is the correct ratio of chest compressions to rescue breaths when performing CPR on an adult? 87 (34) 70 (63) 17 (12) <0.001 What is the proper definition of an open fracture? 126 (49) 68 (61) 58 (39) 0.001 Why should you act quickly for a casualty with severe bleeding? 129 (50) 66 (59) 63 (43) 0.015 Does FA require expensive equipment? 224 (86) 94 (84) 130 (88) 0.386 Practical knowledge What would be your first step if you encountered a person with profuse leg bleeding due to a gunshot wound? 139 (54) 60 (54) 79 (54) >0.999 What would you do first for a person who has burnt his hand with coffee? The affected area is 2–3 inches in size and is red, swollen and painful. 113 (44) 49 (44) 64 (44) >0.999 Which of the following would you do if a woman’s dress sleeve were to catch fire and adhere to her burnt skin? 32 (12) 16 (14) 16 (11) 0.526 What would you encourage your colleague to do if he were to become distressed by a piece of food lodged in his airway? 109 (42) 51 (46) 58 (39) 0.393 What should you do to a person who has fallen down with a suspected thigh fracture? 86 (33) 55 (49) 31 (21) <0.001 Attitude If you have good knowledge of FA, you should not hesitate to use it when needed. 195 (75) 90 (80) 105 (71) 0.299 Do you support including FA in the medical college curriculum? 220 (85) 94 (84) 126 (86) 0.501 Would you like to give a basic idea of FA techniques to your fellow students? 189 (73) 81 (72) 108 (73) 0.730 Do you think FA decreases the burden of hospitals? 177 (68) 82 (73) 95 (65) 0.258 Do you think FA increases patients’ survival rates? 259 (100) 112 (100) 147 (100) >0.999 FA = first aid; CPR = cardiopulmonary resuscitation. *Using a Chi-squared test. Abdulrahman Alshuwayrikh, Abdulrahman Aljethaily, Faris Alosaimi, Osama Alshaya, Abdullah Alasmari, Mohammed Al-Makdob, Saleh Alkhonezan and Salahuddin Khan Clinical and Basic Research | e511 students (63% versus 12%; P <0.001). In contrast, there were no significant differences between FA-trained and untrained students in terms of awareness of the meaning of the abbreviation ‘CPR’ (80% versus 71%; P = 0.105) and whether FA requires expensive equipment (84% versus 88%; P = 0.386). In general, there was a low level of practical knowl- edge among the cohort, with the rate of correct responses ranging from 12–54%. Over half (54%) of the students knew what to do when encountering a bleeding gunshot victim, but only 12% knew how to handle a patient with burning cloth attached to skin. Only one practical knowl- edge question—which involved dealing with a thigh fracture—displayed a significant difference between students with prior FA training and those without (49% versus 21%; P <0.001). With regards to attitudes, the rate of positive resp- onses ranged from 68–100%. All of the participants believed that FA increases survival rates and most students (85%) supported the inclusion of FA training into the medical curriculum. There were no significant differences in the rate of positive responses between FA- trained and untrained students for any of the attitude items (P >0.050 each). Discussion In the current study, medical students at the Al-Imam Mohammad Ibn Saud Islamic University were found to have poor levels of FA knowledge, especially in terms of the practical aspects of FA. The inclusion of FA training in the medical curriculum could improve this deficiency.7,8 Additionally, the study observed a significant difference in knowledge between students with and those without prior FA training; this finding highlights the imp- ortance of including FA in medical education. However, no significant differences were noted in attitude between FA-trained and untrained students. This could imply that willingness to act in emergencies is not enhanced by FA training. On the other hand, the lack of difference between the groups may reflect a lack of confidence among previously trained students. In particular, students untrained in FA showed significant weaknesses regarding their knowledge of diverse emergency situations, indic- ating that FA training should focus on different types of emergencies (e.g. fractures, burns and bleeding). The rates of correct responses to certain FA knowl- edge questions in the current study varied from those reported in other studies. The proportion of students in the present study who knew the correct CPR compr- ession-to-breath ratio was lower than that reported in a previous study conducted in Saudi Arabia (34% versus 53%).6 In a study from Pakistan, Abbas et al. found that 52% and 37.6% of students with and without FA training, respectively, knew how to deal with a bleeding person; in comparison, this percentage was 54% in both groups in the present study.10 The question regarding manage- ment of a choking victim was answered correctly by 42% of the students in the current cohort; this is similar to that noted in Abbas et al.’s study (45.6% and 41.6% for trained and untrained students, respectively), yet lower than that reported by Mejia et al. in Peru (53.4%).10,11 Only 33% of the participants in the present study knew how to deal correctly with a bone fracture. This is higher than that reported by Joseph et al. in South India (12.5%), yet lower than that observed in Khan et al.’s study in Pakistan (44.5%).4,5 Support for the inclusion of FA training was high among current students (85%); Khan et al. reported similar findings (94.4%).4 The present study was limited by the low number of participants in their clinical years. This was likely because most clinical students were undertaking their clinical rotations outside of the college during the distr- ibution of the survey. In addition, the students who com- pleted the online questionnaire had more time and space to complete it than those who completed the paper version. Finally, the findings of the present study were based on data from a single cohort of one medical college in Riyadh; as such, the results cannot be generalised to all medical colleges in Riyadh or to other regions of Saudi Arabia. Larger randomised trials involving mul- tiple cohorts are recommended to provide a higher level of evidence. Conclusion This study found that the overall level of FA knowl- edge among medical students attending the Al-Imam Mohammad Ibn Saud Islamic University was low, pre- dominantly in terms of practical questions. There was a significant difference in knowledge between students with prior FA training and those without, although there was no difference in attitudes between the two groups. These findings support the inclusion of FA in the formal medical college curriculum, particularly in the early stages of medical education. c o n f l i c t o f i n t e r e s t The authors declare no conflicts of interest. f u n d i n g No funding was received for this study. Knowledge and Attitudes Towards First Aid Measures Among Medical Students at Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia e512 | SQU Medical Journal, November 2018, Volume 18, Issue 4 References 1. Singletary EM, Zideman DA, De Buck ED, Chang WT, Jensen JL, Swain JM, et al. Part 9: First aid - 2015 International Consensus on First Aid Science with Treatment Recommendations. Cir- culation 2015; 132:S269–311. https://doi.org/10.1161/CIR.000 0000000000278. 2. Tan EC, Severien I, Metz JC, Berden HJ, Biert J. First aid and basic life support of junior doctors: A prospective study in Nijmegen, the Netherlands. Med Teach 2006; 28:189–92. https://doi.org/ 10.1080/01421590500312847. 3. Tan EC, Hekkert KD, van Vugt AB, Biert J. First aid and basic life support: A questionnaire survey of medical schools in the Netherlands. Teach Learn Med 2010; 22:112–15. https://doi. org/10.1080/10401331003656538. 4. Khan A, Shaikh S, Shuaib F, Sattar A, Samani SA, Shabbir Q, et al. Knowledge attitude and practices of undergraduate students regarding first aid measures. J Pak Med Assoc 2010; 60:68–72. 5. Joseph N, Kumar G, Babu Y, Nelliyanil M, Bhaskaran U. Knowl- edge of first aid skills among students of a medical college in Mangalore City of South India. Ann Med Health Sci Res 2014; 4:162–6. https://doi.org/10.4103/2141-9248.129022. 6. Alanazi A, Alsalmeh M, Alsomali O, Almurshdi AM, Alabdali A, Al-Sulami M, et al. Poor basic life support awareness among medical and College of Applied Medical Sciences students nec- essitates the need for improvement in standards of BLS training and assessment for future health care providers. Middle East J Sci Res 2014; 21:848–54. https://doi.org/10.5829/idosi.mejs r.2014.21.05.82335. 7. Das M, Elzubeir M. First aid and basic life support skills training early in the medical curriculum: Curriculum issues, outcomes, and confidence of students. Teach Learn Med 2001; 13:240–6. https://doi.org/10.1207/S15328015TLM1304_05. 8. Altintaş KH, Aslan D, Yildiz AN, Subaşi N, Elçin M, Odabaşi O, et al. The evaluation of first aid and basic life support training for the first year university students. Tohoku J Exp Med 2005; 205:157–69. https://doi.org/10.1620/tjem.205.157. 9. Tsegaye W, Tesfaye M, Alemu M. Knowledge, attitude and practice of cardiopulmonary resuscitation and associated factors in Ethiopian university medical students. J Gen Pract 2015; 3:206. https://doi.org/10.4172/2329-9126.1000206. 10. Abbas A, Bukhari SI, Ahmad F. Knowledge of first aid and basic life support amongst medical students: A comparison between trained and un-trained students. J Pak Med Assoc 2011; 61:613–16. 11. Mejia CR, Quezada-Osoria C, Moras-Ventocilla C, Quinto-Porras K, Ascencios-Oyarce C. [Level of knowledge in medical emerg- encies among medical students of Peruvian universities]. Rev Peru Med Exp Salud Publica 2011; 28:202–9.