Knowledge of First aid in Nepalese School Students and Teachers.

Background Basic knowledge on rst aid is required to every citizen. School children are best target group for giving such training. School teachers have duel responsibility on this regard. They should have adequate knowledge on rst aid so that they can provide when necessary and to train students. This study was conducted to assess the knowledge of school teachers and students and effect of rst aid training. Methods This study was conducted in school teachers and high school students of 6 schools in Kathmandu. Two days training on rst aid was given to all participants. Knowledge on rst aid was assessed through self administered 10 questionnaires before and after training. Response was recorded as ‘correct’ or ‘incorrect’ of individual question and total score obtained by individual. Responses were compared before and after training and between students and teachers also.


Abstract Background
Basic knowledge on rst aid is required to every citizen. School children are best target group for giving such training. School teachers have duel responsibility on this regard. They should have adequate knowledge on rst aid so that they can provide when necessary and to train students. This study was conducted to assess the knowledge of school teachers and students and effect of rst aid training.

Methods
This study was conducted in school teachers and high school students of 6 schools in Kathmandu. Two days training on rst aid was given to all participants. Knowledge on rst aid was assessed through self administered 10 questionnaires before and after training. Response was recorded as 'correct' or 'incorrect' of individual question and total score obtained by individual. Responses were compared before and after training and between students and teachers also.

Results
A total of 152 participants (121 students and 31 teachers) were included in the study. Average score in pretest and posttest was 5.1 ±1.56 and 8.01 ±1.49 respectively with P value 0.001. Majority were aware of meaning of rst aid, time to perform CPR, and rst aid knowledge on fracture and electric shock. First aid knowledge on other incidents was not satisfactory. The training improved overall knowledge of participants. There was no difference of knowledge in students and teachers.

Conclusion
First aid knowledge of school teachers and students was similar and not satisfactory. Training improves knowledge signi cantly.

Background
First aid is stabilization of injured person by a common person until professional help is available. It is a treatment given by any person who is available near to victim. It is almost impossible to get health personnel immediately at the site of injury. Therefore correct rst aid at correct time is important for saving lives. It requires some knowledge to perform rst aid. Many people lack appropriate knowledge to provide basic treatment for injured person [1,2]. Certi ed rst aid courses for non medical person are available in many developed countries. Studies showed that providing rst aid education to layperson may lead to better outcome in trauma [2]. In an ideal situation, every citizen should be trained for basic life saving procedures. First aid training is essential to obtain driving license and must for employee of kinder garden in many European countries [2,3]. Mortality can be decreased by 1.8-4.5 when effective rst aid is given at incident site [4,5].

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First aid training is not di cult and extensive. Many organizations like Red Cross and ambulance services have designed courses. This training can be easily given to school children. School students have good understanding of the subject and they retain better knowledge if training was taken during school [6]. School children are vulnerable for physical trauma because of their active behavior. School teacher have duel responsibility on this regard. They should have adequate knowledge on rst aid so that they can provide when necessary and they are the best person to train students.
Nepal does not have a law that enforces to take rst aid training for any target group. Different organizations provide this type of training to different target groups. However there is no uniformity of training course and target group. We are providing training to school children and school teachers on request from schools. We conducted this study to measure the knowledge of high school students and teachers before and after rst aid training.

Collection of data
A questionnaire of 10 multiple choice questions was developed including basic knowledge on rst aid and various types of injury. The questionnaire was approved by different trainers of the group. However, external validation has not been done. Self administered pre test of all participation was done prior to training. Similar post test was conducted at the end of training. Mostly Nepali language was used for training and evaluation except for some technical terminology.

Analysis
For analysis, each answer was marked as correct or incorrect. Answer of each question was compared between pre and post test. Total score was compared between pre test and post test. Scores between teachers and students also compared. McNemar's test was used for individual question and paired t test was used to compare total scores. P value < 0.05 was considered as signi cant.

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There were 173 participants in 6 training sessions of 25-30 each. Twenty one participants did not complete the session or did not ll the questionnaire properly and not included in the study. Remaining total of 152 participants were enrolled for study. Among them 121 were students and 31 teachers. Among students 54 (44.6%) were boys and 67(55.4%) were girls. Among teachers, 14 (45.2%) of were females. Students were aged between 14 to 18 years and teachers were between 23 to 47 years.
More than 70% gave correct answer on 'meaning of rst aid', ' rst step on electric shock', 'time to give cardiopulmonary resuscitation (CPR)' and ' rst aid on fracture of bone' before training. Majority do not have adequate knowledge on snake bite, sequence of airway breathing circulation, rst aid on unconscious patients and risks of poisoning before training. There was marked improvement on score on all questions except in poisoning. Correct answer given by all participants is shown in Fig. 1.

Results of individual questions was compared between pretest and post test of students and teachers
separately. Detail of responses is explained in Table 1. The training helped to improve knowledge in 7 out of 10 topics. Majority could not give correct answer on poisoning even after training. Level of knowledge on students and teachers was similar. Students were well aware of use of CPR than teachers.   [7] and many other countries. It is estimated that 1.8-5% of trauma deaths can be prevented if a bystander provides airway and bleeding control at incident site [10]. Worldwide 15%-55% of injured person receive some kind of rst aid by bystander. In such situation if bystander is trained rst aider, quality of rst aid and overall outcome improves [11,12].
Every person may come across such situation where rst aid is required. In a public survey on Norway, 43% had been present at the situation and 89% of whom provided rst aid. A meta analysis showed approximately 10.7-65% patient received some kind of rst aid after trauma and up to 83.7% were given incorrect rst aid [10].
School children are best target group for such training [13][14][15]. Norway has rst aid training as a part of national school curriculum for grade 7-10 [2]. Older person are less likely to be trained [16]. Children of aged 7-14 years are able to perform basic life saving skills. Knowledge and skills seems adequate but they nd thinking algorithm di cult [17]. Studies on Norway, even primary school children had correct knowledge of assessment in emergency and able to perform basic rst aid measures. Knowledge on proper use of semi automated de brillator signi cantly increased after training in children [18]. Overall knowledge was not satisfactory in high school students. Knowledge gradually declines over a period of time. But still remains signi cantly higher if trained in childhood [19].
Our training module included some practical aspects like compression during bleeding, splinting, maneuver for choking, CPR and asked to perform it. The practical performance was also satisfactory. But we did not include in the study as they were not assessed prior to training. Children who are trained in school can teach their family members and friends and have positive attitudes towards bystander for life support. CPR for school children was endorsed by WHO in 2015 [20]. If training is given during childhood, knowledge, skills and willingness to perform in emergency situation increases [13,21]. Some recommend CPR training should be started as early as 10 years [22].
When we target about schoolchildren, we should not forget school teachers. They are the best resource person for children. School teacher who do not have training do not necessarily have adequate knowledge on rst aid. As basic life support is technical subject and all teachers are not aware of it. So we thought of conducting same study on same setting. We nd many of literatures regarding studies on primary, secondary and university students but less with teachers.
Teachers are guardian and protector of school children during school hours. They must be able to deliver rst aid of they sustain injury. In a study in Iran, a cross sectional study of 200 teachers, 48.5% had encountered a situation needing rst aid in school. Most of the teacher's knowledge was insu cient [23]. In India, 72% of teachers had experiences of handling injured children [24].
School teachers also lack of training and knowledge three decades earlier in United States [25]. But the scenario has not changed much at least in developing countries. Overall perception and practice among school teachers were found to be poor in India [26], Ethiopia [27] and Egypt [28]. But teachers have great attitude towards learning and giving when required [29][30][31].
Our study tried to assess knowledge of school students and school teachers through same questionnaire.
Questionnaires were prepared to assess knowledge of general public which includes teachers and high school students. Overall knowledge score was just 50% of total scores. Concept of rst aid was well known for majority of participants. More than 70% were aware of fracture management, electric shock. 'Sequence of airway breathing circulation', ' rst aid measures of snake bite', 'unconsciousness' and 'poisoning' were less known topics to participants. Snake bite is not common in Kathmandu valley.
Analysis of each question helps to plan future training module.
Being a school teacher is not su cient to have adequate knowledge on rst aid. High school students have almost equal knowledge as of their teachers. After training, knowledge of both groups of participant increased signi cantly.

Conclusions
Overall knowledge on rst aid of school teachers and students is not satisfactory. A properly conducted training improves the knowledge on rst aid of school students and school teachers. It is essential to give training to school teachers as they play vital role in teaching students. A second survey after few months is required to check the residual knowledge.

Availability of data and materials
The data used in the current study are available from the corresponding author on reasonable request. Identi cation of participants will not be exposed.