To our knowledge, this is the first survey of BLS knowledge among nurses in Yemen. In general, the results of this study are consistent with other similar studies performed in various countries with similar socioeconomic hardships to those of Yemen, namely that nurses in underdeveloped countries lack adequate knowledge of BLS procedures. We found that 53.65% of answer choices for BLS knowledge were correct and 46.35% of answer choices were incorrect among all surveys completed. This result is similar to results from a study among cardiologists in Istanbul where the median percentage of correct answers was 53%.9 Medical students at a teaching hospital in Oman had a similar mean score, answering 5.5 questions out of 10 correctly as a whole.10 In the present study and those in Oman and Istanbul, all participants had a medical background, which may account for the similar results. In contrast, only 33% of general university students in Lebanon said they felt confident in performing CPR, the mean score among student-teachers at a University in South Africa was 4.0 out of 12 points, and among school teachers in Saudi Arabia there were 1387 correct answers given and 1703 incorrect answers given.11–13 These studies from Lebanon, South Africa, and Saudi Arabia were conducted among the general or non-medical population, which may account for the difference in average scores when compared to studies on medical personnel. Finally, a survey of Nurses in Greece found that 25.9% of participants answered 0 questions correctly out of 8 total questions on BLS knowledge, while only 15.5% answered 5 or more questions correctly.14 This result from nurses is in stark comparison to the present study. One explanation is how recently the persons taking the survey took a training or refresher course on BLS, as only 1.3% of nurses in Greece had taken a BLS course in the preceding 6 months. Taken together, all of these studies point to the fact that medical personnel, who as a whole should have excellent knowledge of BLS and CPR, do not have sufficient knowledge to ensure maximum chances of survival in the case of cardiac arrest or foreign body obstruction of the airway. Recent studies estimate that out-of-hospital cardiac arrest accounts for up to 10% of total mortality in developing countries.15 Ensuring adequate BLS knowledge in medical personnel is a first step in the chain of survival for preventing sudden cardiac death. This study shows that improving BLS knowledge among nurses and eventually among the general population in Yemen could go a long way in reducing mortality from cardiac arrest, ultimately saving countless lives. Discussion on implementation of such training and cost benefit analysis are beyond the scope of this study, however the subject has received worldwide attention and there is plenty of data already published to guide an implementation strategy.16,17 Providing recommendations for improving BLS knowledge in Yemen could be a good topic for future research. On the contrary, the fact that BLS knowledge among nurses in Yemen is comparable to that of other developing countries points to the resilience of the Yemen medical community to the unique socioeconomic hardships in Yemen including war, casualties, famine, an exodus of medical personnel, internal displacement of peoples, and socioeconomic collapse.18 This leads to increases in trauma-related mortality, infectious diseases, malnutrition, and non-communicable disease, along with worsening access to basic health services such as neonatal maternal healthcare which impacts neonatal and maternal mortality rates.19 When combined with less trained medical personnel due to attacks on healthcare facilities or emigration such as in Yemen, the end result is increasing mortality and morbidity with decreasing quality of healthcare services.20
A survey of Medical Schools in Iraq found deans frequently believed violent conflict had negatively impacted student performance.21 Medical students themselves felt their training had been impaired, frequently experienced threats to their lives or health as a result of conflict, wanted to drop out 26% of the time, and were uncertain about dropping out another 25% of the time. This survey highlights some of the hardships that conflict can impart on medical training and the healthcare system. The fact that BLS knowledge among nurses in Yemen has not decreased significantly compared to other underdeveloped nations because of recent conflict will provide a strong foundation for recovery in the future.
The present study found several significant associations which correlated with higher survey scores. Having a Diploma compared to having a Bachelor’s degree was associated with higher survey scores (P < 0.001). Similarly, those who said they had ever received training in CPR or received information about CPR had significantly higher scores than those who answered no to these questions (P < 0.001 for both questions). This result is consistent with studies among cardiologists in Istanbul (P = 0.001), medical students in Oman (P < 0.001), and teachers in South Africa (P = 0.005). However, a study of female teachers in Saudi Arabia found no association between BLS training and knowledge scores, which the study attributed to the fact that many had not had BLS training in the preceding 2 years. Interestingly, being located in the Governance of Hodeidah was associated with significantly higher scores when compared to being located in the Governance of Taiz (P = 0.003). A possible reason for this is that participants from Al-Rahida in the Governance of Taiz are in a rural area without nearby university hospital or BLS training center. In comparison Hodeidah is a more urban environment with a university hospital and training center. This distinction supports the idea of increased BLS knowledge with increased access to training and academic centers. Implementing additional training centers in rural areas would be beneficial.
On the other hand, there was no significant association between knowledge scores and years of experience, age, or sex (P = 0.199, P = 0.48, P = 0.75, respectively). These results are in comparison to those of non-medical personnel in Ethiopia, which did find significant association between knowledge score and both age and sex. This contrast highlights the differences that can arise among different cultural backgrounds as well as the difference between medical and non-medical persons. Those in the medical field would be more likely to have training and exposure to BLS, and so these factors would play a dominant role in knowledge scores. In non-medical personnel, where training may be less frequent, other factors may play a dominant role in knowledge scores, such as age or sex, depending on the societal norms and influences.
Questions which participants were most likely to answer correctly included the meaning of BLS, “What are doing for victim if unresponsive and not breathing normally”, and “Position during chest compression” (80.5%, 79.5%, 67% correct, respectively). This indicates that nurses in Yemen have a grasp of the basic concepts of BLS. However, the low percentage of correct answers to questions like “The rate of chest compressions”, “The ratio of chest compression to rescue breathing for children”, and “chocking during food eating and he can’t cough” indicate that specific knowledge of key BLS procedures resulting in “high-quality” CPR is lacking (25%, 30.5%, and 44.5% correct, respectively).22
Limitations of the study
There are several limitations of this study. As a cross sectional survey conducted among nurses in two governances of Yemen, this study may not be generalizable to other populations and is subject to selection bias and non-response bias. Similarly, the unique socioeconomic factors at play in Yemen present a unique challenge to nurses and the society at large. These factors may impact the concordance of results with those from other countries or from other parts of Yemen. This study only assessed the theoretical knowledge of participants and did not assess the practical skills of participants in performing basic life support.