Effectiveness of First Aid Educational Program on the Knowledge of Primary School Students in Egypt

Background: School students are at high risk of being injured or facing life-threatening conditions. So, improving their knowledge about first aid is essential. Objective(s): To assess first aid knowledge and its determinants among primary school students in Alexandria and measure the level of their knowledge after first aid educational program. Methods: A cross-sectional study followed by a pre-/post-test intervention was conducted on fourth to sixth grade students from the eight districts of Alexandria, who were selected by a multistage random sample technique. Students were invited to fill out a questionnaire to assess their knowledge regarding first aid. Then, educational sessions were conducted using different methods such as group discussions, case scenarios, and visual aids. Finally, students’ knowledge was assessed after the educational program. Results : The current study involved 372 (154 males and 218 females) primary school students with a mean age of 11.49 ± 0.93 years. Among the 15 questions used for assessing the knowledge of students, there was a deficiency in the knowledge about dealing with swallowing a chemical substance, burns, snake bites, epistaxis, bleeding, fractures, and sunstroke. These shortages improved significantly after the educational program. There was a highly statistically significant improvement in first aid knowledge score among the students, from 48.8 ± 11.5% to 87.4 ± 14.6 after the educational program. This improvement was also highly significant among males, females, the different districts and class grades, as well as among those having or not having a working father or mother. Conclusion: School aged children showed high improvement in their knowledge regarding first aid dealing with swallowing a chemical substance, burns, snake bites, epistaxis, bleeding, fractures, and sunstroke after the application of an educational program.


INTRODUCTION
irst aid is the preliminary, immediate help that is given to somebody who suffers an injury or illness at the location where it occurred.Proper and quick administration of first aid could make the difference between life and death.First aid may be simple techniques like cleaning minor cuts, treating a minor burn, and applying bandages, or it may require some training for life support such as cardiopulmonary resuscitation (CPR). (1)s mentioned by the Red Cross, it is expected that up to 59% of deaths from injury could be prevented if first aid was given correctly before emergency medical services arrived. (2)Survival rates of out-of-hospital cardiac arrest are commonly less than 10%, but bystanders CPR have related to survival rates exceeding 50%. (3)Even applying simple techniques at the site of the accident, such as opening the airway and controlling bleeding, could save lives, but unfortunately, only 5% of adults have the skills and self-confidence to offer this simple first aid in emergency situations.So, it is essential to teach everyone first aid measurements for different emergency conditions. (4,5)n general, children of school age are at higher risk of being injured or facing accidents.The high energy levels make them take risky actions without thinking logically. (6)A study carried out in 47 low-and middleincome countries reported that 40% of the students had one serious injury or more in the last 12 months.Also, two-thirds of school adolescents in six African countries reported one or more serious injuries within the past 12 months. (7,8)Broken bones or dislocated joints, cuts, or stab wounds were the most common injuries in some sub-Saharan African countries. (9)egarding Egypt, the prevalence of injury in primary school students in Port Said city was 66.73%, and in secondary school students in Cairo it was 68.5%. (10,11)

Original Article
The participation of children and teachers in health educational sessions on first aid is required for the prevention of injuries. (12)Moreover, some countries have started to include first aid educational program in the school curriculum, such as the Norwegian school system.Applying first aid training in schools leads to educating a large proportion of the population over time. (13,14)t was recommended to integrate age-appropriate first aid and CPR training into the school curriculum from the primary years and to be refreshed annually, as there was significant progression in first aid knowledge and skills after the training session, which may stand or last for up to 12 months. (15)here are few studies exploring the first aid knowledge among the Egyptians.Therefore, this study was conducted to shed light on the importance of first aid educational programs.
The current study aimed to assess the first aid knowledge of primary school students in Alexandria, identify the socio-demographic determinants that could influence their knowledge, and measure the level of their knowledge after a first aid educational program.

METHODS
A cross-sectional study followed by a pre-test/ posttest intervention was conducted in primary schools in Alexandria governorate, Egypt, during March and April 2023.Participants were eligible if they were in fourth to sixth grades of primary schools.Using G. Power software with assumption that the effect of educational program on knowledge of students regarding first aid had an effect size of 0.4, using alpha error of 0.05 and power of 80%, the minimum required sample size is two hundred children.
A multistage random sampling technique was adopted.Alexandria is divided into 8 districts, from each district one primary school was randomly selected.Within the selected schools, two classes were randomly selected among grades from fourth to sixth.Within the selected classes, students were randomly selected to be invited to participate in the study.40 children from each school were selected so the sample size was 320 (40*8) students.

Data collection method and tools
A pre-designed pre-coded structured interviewing questionnaire for students was used to collect the data.(18) Two professors of emergency medicine and public health were asked to validate the questionnaire and make sure it was in line with the goals of the study and the target population.A pilot study was carried out prior to data collection (that was not part of the survey).Each investigator was requested to provide ten replies to calculate the time needed to complete the survey and to examine the clarity and understandability of the questionnaire.Based on the pilot results among 20 students, the time needed to fill out the questionnaire was 5-15 minutes, and a few sentences needed fine wording to be more comprehensible.
The Arabic questionnaire consisted of two parts:

Educational program
An educational program was implemented for the study sample of students to improve their knowledge regarding first aid measures.Two educational sessions were conducted at school (about 20 students in each session).The session lasted for 45 minutes.The educational information covered causes and immediate corrective responses for the most common urgent medical conditions and the common mistakes that should be avoided when applying first aid measures.The lectures included first aid measures for swallowing of caustic chemicals, skin burns, inhalation of poison, snake bites, external bleeding, epistaxis, fractures of bones, heat stress and exhaustion, body catch of fire, and suffocation.Training was conducted through different educational methods, including group discussions, case scenarios, and visual aids.Evaluation of the training sessions was conducted using the same knowledge questionnaire immediately after the end of the educational program.

Ethical considerations:
The approval of the Directorate of Education in Alexandria and each school was obtained.The researcher sought the approval of the Ethical Committee of the High Institute of Public Health, Alexandria University, Egypt (I.R.B.No. 00013692).The purpose of the research was stated at the beginning of the sessions, and participants or their caregivers were able to accept or reject to participate.They were able to withdraw from the study at any time before its completion.The researcher complied with the International Guidelines for Research Ethics.

Statistical analysis
The collected data were coded, revised, cleaned, tabulated, and analyzed through IBM SPSS Statistics version 26 using appropriate statistics.The descriptive statistics including percentages (%), arithmetic mean and standard deviation (SD) were calculated for various qualitative and quantitative data to describe the study population.The analytic statistical tests comprised Chi squared (χ 2 ), student t test, paired t test and repeated measures analysis of variance (ANOVA) for various comparisons of the studied variables.In all applied statistical tests of significance, p value (< 0.05) was considered significant.

RESULTS
The current study involved 372 (154 males and 218 females) primary school students among the 8 districts of Alexandria with a mean age of 11.49 ± 0.93 years.Most of them have a working father (98.4%) and a non-working mother (81.5%).[Table 1] ).Gender and having a working father or mother did not affect the knowledge score among the students before or after the educational program.There was a highly statistically significant improvement in the knowledge score among the students from 48.8 ± 11.5% before to 87.4 ± 14.6% after the educational program.This improvement was also highly significance among males, females, the different districts and class grade and also among those having or not having working father or mother.
[Table 2 & Figure 1] Among the 15 questions that have been used to assess the knowledge among the students, only 4 did not reveal improvement in the answers after the educational program.However, the remaining 11 questions entitled showed a high statistical correction of answers after the educational program.The first question was about inducing vomiting in someone who swallowed a chemical substance (acidic or alkaline substance).The correct answer would be "no", as the person could aspirate the chemical substance during vomiting.Thirty (8.1%) participants answered correctly before the educational session, whereas 335 (90.1%) students correctly answered the question after it with statistical significance (<0.001).
The second question was about the site of treatment for a person exposed to inhalation poison.The person should be removed from this place to avoid further inhalation by the victim or the helping person.Most of the pupils answered the question correctly before and after the educational program (332 (89.2%) before and 335 (90.1%) after the educational session).Surprisingly, question number 8 asked about the same situation but in a reverse manner.The majority answered wrongly, despite a slight increase in the right answer after the session (350 (94.1%) with the wrong answer before and 348 (93.5%) after the session).The next question reviewed the answers about removing clothes stuck to burns.The correct answer was "no", as the skin will be removed with the clothes.There was a significant difference between the answers before and after the educational session (62 (16.7% versus 316 (84.9%) after the session with p <0.001).The fourth question asked about moving the limb that was bitten by a snake.The victim should not move the limb, as this would enhance the circulation in the limb by moving the poison to other parts of the body.The educational session significantly corrected the knowledge of the pupils (87 (23.4%) had correct answers before and 338 (90.9%) after the session with p <0.001).The skin in the second-degree burn has bubbles, but not in the third-degree.The students significantly corrected their knowledge after the session (74 (19.9%) students before versus 299 (80.4%) after the educational session, p <0.001).
The bleeding area must be pressed until the bleeding stops.The correct answer was "yes" Fourfifths of the students correctly answered the question before the session with mild improve after the session.
The next question asked about tilting the head back in cases of epistaxis.This is wrong, as it may cause aspiration.A statistically significant correct result was obtained after the session (124 (33.3%) before versus 332 (89.2%) after the educational session, p <0.001).The bleeding should not be stopped with a tissue (a cotton piece), as it will stick to the injured tissue.Significant improvement in knowledge about this point was observed after the educational session (97 (26.1%) before versus 335 (90.1%) after the session with p <0.001).
Regarding the question about tying the site after the snake bite, the correct answer was to tie the limb above the injured area to reduce the blood flow, with the toxin coming back from the limb to the heart.The correct answers of the students increased significantly after the educational session (254 (68.3%) before versus 323 (86.8%) after the session with p <0.001).The ice should not be used to soothe burns, as it might cause severe vasoconstriction of the blood supply in the affected area, and if it is applied to a large area, it would lead to hypothermia.More pupils correctly answered the question after the session (60 (16.1%) students before and 301 (80.9%) after the session with p <0.001).The fracture should not be repaired immediately before going to the hospital; fix the limb only as any movement may cut muscles, nerves, tendons, or blood vessels.The students' knowledge improved after the session (123 (33.1%) students before and 286 (76.9%) after the session with p <0.001).
Fluids should be given to the person suffering from heat exhaustion or sunstroke.Surprisingly, the percentage of students who answered correctly to the question decreased after the educational session.This may be due to the confusion they faced about whether the patient was awake or unconscious, as no fluids should be given by mouth to unconscious patients for fear of aspiration, so the pupils mistakenly thought the victim had lost consciousness in this situation.Concerning dealing with a person who caught fire, the person should not run, as the running victim would be exposed to more oxygen, and then the fire would increase.Pupils' knowledge had significantly corrected after the educational session (149 (40.1%) before and 355 (95.4%) after the session with p <0.001).The last question was about encouraging patients to cough in cases of airway obstruction.Most of the students answered correctly to the question before and after the educational session.[Table 3 Table

DISCUSSION
There is a need to integrate first aid information into the school curriculum in Egypt, as the poor knowledge of the students leads to delays in the rescue, which endangers the life or application of fault techniques to the victim, resulting in major harm.About 3/4 of the students reported that they have suffered one accident or more in their life among the studied participants in Hungary. (19)Eldosoky, in a cross-sectional study, stated that 38.3% of the children experienced injuries in the previous month in Qalubeya governorate, Egypt.
The most frequent types of injuries are cut wounds, falls and fractures, burns, poisoning, and foreign body aspiration. (20)n the present study, we tried to figure out the degree of the first aid knowledge of the primary school children in the Alexandria governorate and implement an educational session to assess the improvement of the knowledge after it.Students had poor knowledge about the first aid of swallowing a caustic substance, skin burns, snake bites, epistaxis, bleeding, bone fractures and sunstroke.Similar results were reported from previous studies where primary school students or even undergraduate students failed to identify the correct management for shock, gastroesophageal reflux disease, epistaxis, foreign bodies in the eyes, trauma, and choking. (21,22)n the current study, children in the sixth grade had a higher score for knowledge than those in the lower grade, with a statistically significant result indicating that those of older age had more knowledge.In compliance, a Portuguese study documented an increasing trend in the score of first aid knowledge with the participants' age. (23)he result of the current study revealed a significant improvement in the knowledge of the students regarding first aid (from 48.8 ± 11.5% before the educational program to 87.4 ± 14.6% after it, t-test -40.028, p <0.001).The progression was also statistically significant for all tested categories (males, females, the different districts, and class grade, among those having or not having a working father or mother (p <0.001)).Similar results were found in a study carried out in Ahmedabad, India, assessed the knowledge of about 300 students about first aid using a questionnaire, then re-evaluated the students' knowledge after an educational session on the same day with the same questionnaire.Also, knowledge about different aspects of first aid improved after the educational session to range from 39% to 92.33% when compared with its range before the training (7.66% to 63.33%). (24)A study held by Ajani et al. among Indonesian school students found an improvement in the knowledge of junior high school students after simulation methods for handling emergency situations. (25)he highly significant improvement may be because school-aged children are more likely to learn quickly and easily accept first aid training than older people.We hope the students share the acquired information with their families and friends; hence, we indirectly teach a larger portion of the community about first aid.
Regarding the questions asked, 11 out of 15 questions showed significant improvement after the implementation of the educational program.Those questions were about dealing with swallowing a chemical substance, burns, snake bites, epistaxis, bleeding, fractures, and sunstroke.In the same vein, Das et al. noticed a significant improvement in the knowledge of the students in many fields of first aid.The scores of knowledge concerning fainting (17.4%), poisoning (17.9%), and heat exposure (50.7%), elevated significantly to 52.7 %, 65.75%, and 69.2%, respectively, after the educational intervention. (26)he same results were found in adults.Delaney et al. reported an improvement in the first aid knowledge of the general population in Uganda after the implementation of the educational program. (27)imitations of the current study included firstly, the evaluation of the educational sessions should be repeated after 3 to 6 months, but as the study was held in the second semester, we could not allocate the same students after this period as they would be on holiday.Second, the questionnaire may need to include more items about basic life support.Despite its limitations, this study sheds light on the critical shortages in the first aid knowledge of the students and encourages the government and public health managers to create and involve first aid concepts in the educational curriculum.

CONCLUSION AND RECOMMENDATIONS
School-aged children showed a high improvement in their knowledge after the application of an educational program concerning dealing with swallowing a chemical substance, burns, snake bites, epistaxis, bleeding, fractures, and sunstroke.This favors integrating first-aid educational programs into the school curriculum in Egypt, which could reduce the consequences of injuries and major accidents.

Figure 1 :
Figure 1: Knowledge percentage difference among primary school students before and after the educational program in Alexandria, Egypt

Table 1 : Socio-demographic characteristics of the studied primary school students in Alexandria, Egypt
districts and between the 3 class grades involved before and after the educational program.The highest score was among Borg Al Arab district (54.3 ± 14.0%) and the sixth grade (51.4 ± 11.4%) while the lowest was among Central district (42.1 ± 7.95%) and the fifth grade (46.7 ± 10.8%) before the educational program.Regarding after the program, the highest score was among Al Agamy district (94.97 ± 7.5%) and the sixth grade (92.5 ± 10.3%) and the least was among Western district (67.1 ± 17.3%) and the fifth grade (83.7 ± 16.8%