Student's Knowledge, Attitudes, and Practices Related to Cardiopulmonary Resuscitation at Qassim University, Saudi Arabia

Background Cardiopulmonary resuscitation (CPR) is a lifesaving technique that is vital to deal with in many emergencies. Early interference with the cardiopulmonary resuscitation technique is really important for the survival of the patient. This study assesses the level of knowledge, attitudes, and practices regarding CPR among Qassim University students. Materials and methods A cross-sectional study was conducted at Qassim University. The sample was university students. The colleges were chosen by a simple random technique. Data were collected using a pretested, semi-structured questionnaire for knowledge, attitudes, and practices related to CPR. The data were analyzed using Statistical Package for the Social Sciences (SPSS; IBM Corporation, Armonk, NY). Results The total sample size of the participating students was 1148, of which 589 (51.3%) were female and the remaining were male (559, 48.7%). The common age was between 20 and 23 years old and most were from non-medical colleges (54.1%); the remaining (45.9%) were from medical colleges. The majority of female students (45.7%) in medical colleges knew the right location for chest compression better than the males, with a significant difference (p<0.05). No significant difference existed between males and females (p>0.05) regarding most CPR practices. On the other hand, there was a significant increase among medical students as compared to non-medical students (p<0.05) regarding most knowledge, attitudes, and practice items of CPR. Conclusion Based on our study, the knowledge, attitudes, and practices of Qassim University students toward CPR are insufficient and need to be improved. Also, medical students are better than non-medical students at CPR, so we recommend that the incorporation of a Basic Life Support (BLS) course, including CPR learning procedures in the university curriculum, with regular reassessments, would increase the knowledge and application of CPR skills among students for saving people's life.


Introduction
Cardiopulmonary resuscitation (CPR) is the first prompt and initial action provided to a cardiac arrest patient. In the best possible condition, this efficient action is taken to keep the patient alive until emergency medical services and treatment can be obtained. Early intervention with the CPR technique is crucially important for the survival of the patient. The more effective and efficient the caregiver or 'bystander' is, the better the results will be on the ground [1].
Cardiac arrest is the sudden stopping of the pumping function of the heart and, therefore, the need for CPR for people whose hearts or breathing has stopped. The mechanism of CPR is performed by doing rescue breathing and chest compressions. It is known that about 75% of cardiac arrests happen at home. Therefore, the need for CPR by bystanders emerges to raise the chances of survival of the patient. Studies have shown that immediate and successful CPR may raise the chance of survival from double to triple [2][3].
Sudden cardiac death (SCD) is a common and devastating event, often occurring in the early age of one's life. SCD is considered to be the most common and leading cause of death outside the hospital worldwide. In the USA, according to one study, the incidence of SCD was found to be 300,000-450,000 per year. Researchers also found that the peaks of SCD are bimodal, occurring at the age of infancy and after the age of 45. In the USA, almost 50% of adults who suffer from SCD were found to have coronary heart disease (CHD). One study was done on New Zealand's high-school students to assess the level of the knowledge of the students towards CPR. The students showed a poor understanding of resuscitation; only 22% of them knew what CPR means [4][5].
According to one study on King Saud University students in Riyadh, Saudi Arabia, it found that 31% of the students had no idea about CPR, 85% felt that their knowledge was weak, and 10% believed that their knowledge was good [6].
According to our search, no study was done regarding the knowledge and attitudes towards CPR that has included all Qassim University students in the Qassim region of Saudi Arabia. So, our study was conducted to assess the level of knowledge, attitudes, and practices regarding cardiopulmonary resuscitation among all Qassim University students.

Study design
A cross-sectional study was conducted during the academic year 2018-2019.

Study setting
Students of Qassim University, Qassim region, Saudi Arabia

Sample size
The study participants are samples from the students of Qassim University. The colleges were chosen by the simple random technique. The sample size was calculated by using a specific sample size equation for a cross-sectional study: n = Z² (1-α) p (1-p) /d² The total sample size was 1148 students from seven colleges.

Attitudes of students towards CPR
About 55.5% of students think that a CPR training course is mandatory for all students as a graduation requirement, and about 40.1% of them stated that the best method to increase public awareness of the importance of CPR is to inform people about the currently available training courses. The majority of students strongly agree and also agree about the benefits of CPR training courses to public life saving (66.9% and 24.9%, respectively). Also, most students (77.5%) did not have a CPR training course, and the majority of them (82.5%) wanted to learn CPR (

Practices of students towards CPR
With regards to the first response of students when they saw a comatose person, most of them stated that they looked for safety and open airways (46.4% and 35.5%, respectively). The majority of students would activate emergency medical services (EMS) and start CPR if someone did not respond by moving or talking (47.9% and 35.8%, respectively). Of the students, 34.4% would do mouth-mask ventilation and chest compression during CPR if they did not want to give artificial respiration. Of the participants, 37.9% will give abdominal thrusts to their friends if they were exposed to choking during eating. About 50% of students would do back blows and chest compression for five cycles and then open the mouth and remove the foreign body if they watched a child who suddenly started to choke. Of the participants, 42.9% would compress the abdomen to remove water for a drowned person. Of the students, 43.5% would take their colleagues to the nearest clinic if they were not able to speak and exposed to weakness in the right upper limb ( Table 4).

N=1148 Percent
If Keep him in the recovery position 120 10.5 You noticed that your colleague was not able to speak and he exposed to weakness in the right upper limb which one of the following could be done

Gender comparison for knowledge and attitudes
Male students (58.3%) knew the emergency telephone for Saudi Red Crescent more than females did, but the majority of female students (45.7%) knew the right location for the application of chest compression more than males did, with a significant difference between them (p<0.05) and 43.6% of female participants knew the proper depth of chest compression and the rate of CPR (23.9%) more than males did, with no significant difference between them (p>0.05). The majority of female students thought that the CPR training course is mandatory for all students as a graduation requirement (62.1%), and they mentioned that the best method, in their opinion, to increase the awareness of the public regarding the CPR training course is to inform people of the training courses currently available (44.8%). They also strongly agreed that the CPR training course is beneficial for students to save the lives of the public (73.7%). And most of them (86.6%) wanted to learn CPR more than males did, with a significant difference between them (p<0.05) (

Gender comparison for practices
In regards the practice of CPR, there is no significant difference between males and females (p>0.05) in their first response if they saw a comatose person, giving abdominal thrusts if their friend was exposed to choking during eating, and compressing the abdomen to remove water if they saw a person drowning and not responding. But there is a significant increase among females rather than males (p<0.05) regarding the activation of EMS, starting CPR for someone not responding to moving and talking (48.0%), implementing back blows and chest compression of five cycles followed by opening the mouth and removing the foreign body on watching a child who suddenly started to choke (50.3%), and getting their colleagues to the nearest clinic if they were not able to speak and were exposed to weakness in the right upper limb (46.2%) (

Medical and non-medical comparison of knowledge and attitudes
There was a significant increase among medical students rather than non-medical students (p<0.05) regarding knowledge and attitude for knowing the emergency telephone of Saudi Red Crescent (61.1%), proper chest compression depth (44.2%), and their thinking that a CPR training course is mandatory for all students as a graduation requirement (66.4%). Their opinion regarding the best methods for increasing the awareness of the public about CPR was to inform people of the training courses currently available (42.9%). They strongly agreed that a CPR training course is beneficial for students to life-save the public (78.6%); 87.9% of them wanted to learn CPR. But there is no significant difference between medical and non-medical students (p>0.05) regarding the right location for the application of chest compression and the chest compression rate ( Table 7).

Medical and non-medical comparison of practices
As regards the practice of CPR among medical and non-medical students. there is a significant increase among medical rather than than non-medical students (p<0.05) regarding their first response if they saw a comatose person (36.8%) and for giving abdominal thrusts if their friend was exposed to choking during eating (45.2%), the activation of EMS and starting CPR for someone not responding to moving and talking, implementing back blows and chest compression of five cycles, opening the mouth and removing the foreign body on seeing a child who suddenly started to choke (58.1%), and getting their colleagues to the nearest clinic if they not able to speak and were exposed to weakness in the right upper limb (51.8%). But there is an increased significance of non-medical rather than medical students for compressing the abdomen to remove water if they saw any person drowning and not responding (46.2%) ( Table  8).

Discussion
Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including a heart attack or near drowning, in which someone's breathing or heartbeat has stopped. The American Heart Association recommends that everyone -untrained bystanders and medical personnel alike -begin CPR with chest compressions. It's far better to do something than to do nothing at all if you're fearful that your knowledge or abilities aren't 100% complete. Remember, the difference between your doing something and doing nothing could be someone's life [6].
The current study aimed to assess the level of knowledge, attitudes, and practices regarding cardiopulmonary resuscitation among Qassim University students.
The present study finds that around half of students don't know the emergency telephone of Saudi Arabia Red Crescent (45%). This is agreeing with another study conducted at Jouf University, which stated the same results. But it is less than another study conducted at King Saud University, which revealed that 70% of their students knew the Red Crescent telephone number [5,7].
On the other hand, this study showed that only 44% of students knew the right location of chest compression in CPR and this is in accordance with another study conducted at Qassim University, which revealed nearly the same results (40.0%) [8].
Furthermore, this study showed that only (40.8% and 24.2%, respectively) of students have insufficient knowledge regarding the proper chest compression depth in CPR and the chest compression rate for adults and children and this is due to the small number of training programs for CPR skills conducted at Qassim University. Also, there is no inclusion of a BLS course in the university curriculum for comparing with other students at King Saud University, which revealed sufficient knowledge 69% and 55%, respectively. However, this result is nearly the same as another study conducted among secondary school students in Riyadh and has better knowledge than another study conducted at Qassim University in 2014 [8][9][10].
As regards the attitudes of students towards CPR, the majority of students in this study (55.5%) think that the training program for CPR is mandatory for graduation, and it benefits them in saving the lives of people (66.9%). These results are better than another study conducted on university students in Riyadh, 2008, which found that only 45% of their students believe that it is mandatory for graduation [5].
On the other hand, the majority of students in this study wanted to learn CPR (82.5%), and this is a good, positive attitude among them. Also, this result is in accordance with another study conducted in New Zealand, which found nearly the same results (73.5%) and with a study that was conducted in Riyadh, 2008, which showed better attitudes (90%). These results reflect the importance of a CPR training program for university students and their benefit to them. The majority of students in our study think that the best way to increase the awareness of the public towards CPR is to inform them about the availability of training programs (40.1%). These results disagree with another study conducted in Riyadh, which shows that about half of the students believe that the media such as television and social media is the best way to increase the awareness of people [5,11].
Regarding the practice of students towards CPR, only 46.4% and 35.5% respectively, would look for safety and open airways in comatose persons. And this is insufficient practice for saving lives; this result is supported by another study conducted in 2014 at Qassim University, which revealed that the first practice for a comatose person is to look for safety and then an open airway. Furthermore, our study stated that the majority of students (47.9%) would activate EMS if they saw someone does not respond to moving or talking, and these results are in accordance with the same study conducted in 2014 [8].
On the other hand, this study stated that only 37.9% of participants would give abdominal thrusts to their friends if they are exposed to choking during eating. This is less than in another study conducted in 2010, which shows a higher level of practice (54.1%). Also, the present study finds that 50% of students will do back blows and chest compressions of five cycles, open the mouth, and remove the foreign body if they are watching a child who suddenly started to choke, and about 42.9% of the participants will compress the abdomen to remove water in a drowned person. This is in accordance with another study done in 2015 at an Ethiopian university. Furthermore, the current study shows that about 43.5% of students will take their colleagues to the nearest clinic if they were not able to speak and exposed to weakness in the right upper limb, and this indicates that they have good practice in this situation for saving the lives of their colleagues [12][13].
In spite of these results, the current study revealed that there is a significant increase of knowledge and attitudes regarding CPR among females rather than males in the majority of items and no significant difference between them in most practices. This indicates that the awareness of female students is better than that of males and similar results were find in other studies conducted in 2014 at an Ethiopian university and in 2015 in Hong Kong [13][14]. On the other hand, the present study shows that there are significant increases of knowledge, attitudes, and practices regarding CPR among medical students rather than non-medical students at Qassim University, and this is because their college curriculums will help them and increase their awareness regarding CPR, and there are no other studies done to support this results [13][14].

Conclusions
Based on our study, the knowledge, attitudes, and practices of Qassim University students related to CPR are insufficient and need to be improved. Also, medical students are better than non-medical students and females are better at CPR than males so we recommend the incorporation of a BLS course, including CPR learning procedures, in the university curriculum, with regular reassessments, would increase the knowledge and application of CPR skills among students to save people lives.

Additional Information
Disclosures