Public Attitude and Knowledge in the Makkah Region Regarding Providing First Aid before and after the COVID-19 Pandemic

Aims: To evaluate attitude toward and knowledge of first aid of the public in Makkah region, Saudi Arabia, considering the effects of the COVID-19 pandemic on changing perceptions. Study Design: A descriptive cross-sectional study. Place and Duration of Study: Department of Medicine, between June 2020 and November 2021. Methodology: A descriptive cross-sectional study targeted the whole accessible population in Makkah region. All those aged 18 or older living in the region were invited to participate in the survey. Data collection was through an online pre-structured questionnaire from July 15th to August 12th, 2021. It covered sociodemographic data, knowledge, and attitude regarding first aid, and the effects of the COVID-19 pandemic. Original Research Article Alnofaiey et al.; JPRI, 33(52B): 111-119, 2021; Article no.JPRI.77755 112 Results: A total of 1,368 participants met the inclusion criteria. Ages ranged from 18 to 70 years. A total of 1,132 (82.7%) participants had poor knowledge, and 1,028 (75.1%) reported they would help in providing first aid. Conclusion: Despite high motivation and readiness to attain knowledge of first aid, public knowledge was very low. Attitudes were very good, but practice was restricted by some barriers.


INTRODUCTION
First aid is the immediate care that can be provided by any member of the community to an ill or injured person until the arrival of emergency medical services [1]. The importance of first aid is mainly in saving lives and decreasing morbidity by stabilizing the casualty and preventing their condition from deterioration [1,2]. First aid can be provided with any level of training. A general characteristic of such training is being able to recognize situations in which emergency medical services are needed [3]. Though research in this area is scarce, studies have shown that early correct cardiopulmonary resuscitation enhances the general outcomes of out-of-hospital cardiac arrest cases [4].
First aid and basic life support include life-saving medical techniques that a person, either in the medical field or not, can be trained to perform with available equipment. If persons are properly equipped with basic first aid information, this can save lives, lessen morbidity, and reduce the costs of treatment or rehabilitation [5,6]. The proper application of first aid can help immensely in some emergency cases [7][8][9]. With an upward trend in the incidence of emergencies, all individuals must be adequately trained to deal with such events [10].
Public attitude and knowledge in the Makkah region regarding providing first aid have not yet been comprehensively explored. To provide targeted education and training, we must first measure the level of knowledge and willingness to help, especially now in the COVID-19 era. This study aimed to assess the public knowledge and attitude in the Makkah region regarding providing first aid, explore COVID-19 changes to the perceptions of providing first aid, and estimate whether the public are aware of guidelines to protect themselves and the casualty in the COVID-19 era.

MATERIALS AND METHODS
A sample size of 1067 was determined with a confidence level of 95% and a confidence interval of 3 in the context that the Makkah region population was 8558000 people. This descriptive cross-sectional study targeted the whole accessible population in the Makkah region, Saudi Arabia. All those aged 18 or older living in the region were invited to participate in the survey. A total of 1,570 individuals received the study survey, and 1,368 were eligible and completed the questionnaire, giving a participation rate of 87.1%. The data was collected using an online pre-structured questionnaire, carefully constructed with an extensive literature review and expert opinions in mind. The questionnaire then was reviewed for applicability and approved by a panel of three experts. Its reliability was assessed using a pilot study of 30 participants, giving a reliability coefficient (Cronbach's α) of 0.79 for knowledge and 0.71 for attitude. The questionnaire covered participants' sociodemographic data; knowledge, assessed using eight questions with one correct answer for each; attitude, assessed by four items with agree/disagree choices; and practice regarding first aid, assessed using two questions. The questionnaire was uploaded online using social media platforms from July 15th to August 12th, 2021.

Data Analysis
All collected data were extracted, revised, and coded, then processed using IBM SPSS version 22 (SPSS, Inc., Chicago, IL, USA). Two-tailed tests were used for all statistical analyses. Pvalues less than .05 were considered statistically significant. For knowledge items, each correct answer was scored one point, and the total of the item scores was calculated. A participant with a score less than 60% (6 points) of the maximum was considered to have poor knowledge, and a good knowledge level was considered a score of at least 60% (7 points or more) of the maximum. Descriptive analysis based on frequency and percent distribution was done for all variables, including demographic data, history of first aid training, and knowledge and attitude regarding first aid learning and its importance. Crosstabulation was used to assess the distribution of knowledge level according to participants' demographic data. Relationships were tested using Pearson's chi-square test.

RESULTS AND DISCUSSION
A total of 1,368 participants met the inclusion criteria. Their ages ranged from 18 to 70 years, with a mean age of 27.6 ± 10.8 years, and 1,124 (82.2%) were women. Of the participants, 405 (29.6%) were non-healthcare workers, 87 (6.4%) were healthcare workers, and 746 (54.5%) were students. A total of 439 (32.1%) participants had taken a first aid course, 218 (49.7%) of them at school or work and 221 (50.3%) by their own effort ( Table 1).
Asked about the first step for a middle-aged person lying on the ground motionless, 47.4% correctly selected monitoring breathing and calling to them to assess consciousness, 18.6% of participants said they would place them in the recovery position to help breathing, and 34.1% reported they would call an ambulance.
Identifying the cardiopulmonary resuscitation (CPR) procedure for an adult, 34.9% correctly responded that chest compressions are more important than rescue breaths, 47.1% answered that chest compressions should be in the middle of the chest and to a depth of 8 cm, and 17.9% said that the rate of chest compressions should not exceed 90 per minute.
Regarding how to help a person who needed CPR during the COVID-19 pandemic, 53.7% correctly responded that the rescuer can perform chest compressions without rescue breaths while wearing a mask, 36.1% selected that chest compressions can only be performed if the casualty's COVID-19 status is known, and 10.2% thought that wearing a mask for the rescuer or casualty is not important and the chance of infection transmission is small.
In the scenario of a person standing from their chair, pointing to their neck and unable to speak or cough, 70.4% of participants knew that they should perform back blows with the palm between the shoulders up to five times, 18.3% chose trying to retrieve the stuck object from the mouth even if it was unseen, and 11.3% selected calling an ambulance.
To help a person after a traffic accident who was bleeding heavily from a cut on the arm but not unconscious, 42.9% correctly selected ensuring the safety of the crash site and then applying pressure to the bleeding site with a clean cloth, 36.1% said they would cover the bleeding site .0% A person stumbled and fell while playing sports, after examining the leg and found that it was swollen and the bone seemed to be in an abnormal position, how do you deal with the situation? Keep the leg in its current position and limit its movement, then call an ambulance 1107 80.9% Compress the leg with ice and then return the bone to its normal position 118 8.6% Returning the bone to its normal position and then tying it with an elastic bandage to reduce swelling 143 10.5% A family member was bitten by a snake, which of the following is the right thing to do while you wait for the ambulance? Tie the affected part over the sting site to limit the spread of poison 1103 80.6% Limit the movement of the affected part and place it below the level of the heart 212 15.5% Compressing the affected part with ice to reduce pain 53 3.9% with a clean cloth and raise the hand above the level of the heart, and 21% reported they would tie the hand over the bleeding site, then raise it above the level of the heart.
For someone who poured boiling water on their hand, 55.6% correctly chose washing with tap water for 10 minutes, 27.4% selected washing with ice water then covering with a clean cloth, and 17% thought that they should put a layer of toothpaste on the burn.
For a person who stumbled and fell while playing sports, whose leg was swollen with the bone seemingly in an abnormal position on examination, 80.9% of participants said they would keep the leg in its current position, limit its movement, and then call an ambulance. Another 10.5% chose returning the bone to its normal position and then tying it with an elastic bandage to reduce swelling.
In case of a snake bite, only 15.5% knew that they should limit the movement of the affected body part and place it below the level of the heart, whereas 80.6% reported that they would tie the affected part over the bite location to limit the spread of poison.  Table 3 illustrates the distribution of public practice and motives for first aid. Of the study participants, 75.1% reported that they would help with providing first aid for a person who appeared to need it, whereas 26.2% would not help because they had insufficient knowledge. Other reasons included fear that the person may have COVID-19 (8.5%), fear of legal responsibility (8.9%), and thinking that someone else would help (5.1%). The most common motive for participants to take a first aid course was helping community members (80.9%), followed by helping relatives when needed (52.4%), to strengthen their curriculum vitae (27.6%), and as a requirement for a job they had or wanted (11.8%). Table 4 demonstrates the distribution of public attitudes toward first aid. Most participants (99%) agreed that knowing first aid is important for all members of society; only 11.2% agreed that learning and providing first aid is solely for health workers and students. Additionally, 99.2% thought that correctly providing first aid improves the chances of survival or recovery for the casualty, and 40.3% reported that the COVID-19 pandemic had changed their view of providing first aid for fear of infection. Table 5 shows the distribution of overall public knowledge of first aid by participant demographics. A good knowledge level was found among 23.2% of young participants (aged 18-20 years) compared to 8.6% of those aged 40 years or above, a statistically significant

Discussion
Through this study, we aimed to investigate the evidence on public knowledge and awareness regarding first aid in the Makkah region, as well as the COVID-19 pandemic's effects on the public's beliefs about first aid and whether they are aware of guidelines to protect themselves and casualties in the COVID-19 era. The issue of knowledge and attitude regarding first aid is rarely researched in Saudi Arabia. Though a very important subject, we found that it has only been researched on a smaller scale inside schools or universities. Correct application of first aid, such as maintaining upper airway patency, CPR, applying pressure on an injured vessel, and positioning the casualty safely, has a significant role in saving the lives of many, especially following accidents [11][12][13].
This study found that public awareness and knowledge in the Makkah region was very poor, with less than one fifth of participants having a good knowledge level (17%). Less than half of the participants correctly reported safe actions for each situation, except for the choking scenario. Knowledge of putting the casualty in the recovery position, maintaining airway patency, CPR and rescue breath techniques, dealing with burns from hot fluids, emergency fracture management, and dealing with snake bites was not satisfactory among the study population. Calling an ambulance was a moderately commonly selected solution for some situations. This study did not assess the public awareness of CPR techniques in more detail or public knowledge of emergency care contact numbers.
Knowledge was significantly higher among healthcare workers (explained by their medical background), younger participants (who were mainly students or healthcare workers), and those who had first aid training. Surprisingly, those who self-initiated learning had higher knowledge of first aid than those who were trained at work or school. This could be explained by the assumption that most of those who trained at work or school were obligated but not motivated and thus attending with little care, in contrast to others who were motivated to learn and searched for courses themselves.
Krammel et al. [14] reported that more than half (52%) of participants in Vienna, Austria, would correctly provide first aid for an out-of-hospital cardiac arrest and would properly initiate basic life support attempts. Only 33% reported that they would be willing to perform CPR, and 50% would use an automated external defibrillator device. Brooks et al. [15] found that 61.1% of urban residents in the UK had basic life support training. Around 70% knew what an automatic external defibrillator was, and 26.1% know how to use one. Only 3.3% of participants would attempt locating a defibrillator, but 2.1% would retrieve and use it. Krzyszkowska [16] found that 164 of 250 (65.6%) respondents had a good level of knowledge of first aid. Only 80 respondents (32%) had an average level of knowledge.
In Saudi Arabia, no study has assessed public awareness regarding first aid. In Khobar, Al-Turkistani et al. [17] found that 80.8% of females and 86.5% of males were totally unaware of CPR. Of female participants, 15.5% had attended CPR courses, in comparison to 6.1% of males; 18.7% of females had reviewed CPR programs or videos versus 11.1% of male participants. More females (59.4%) were enthusiastic about learning CPR than males (29.3%). A 2019 study of Taif University students showed a very poor attitude toward providing first aid, matching with the current study findings [18]. Another study, conducted on female students in Princess Norah University, Riyadh, showed that participants had a good attitude. However, 35% of participants did not provide CPR when faced with a situation in which it was needed, due to a lack of knowledge, nervousness, and other reasons unspecified by the study [19]. A study published in 2020 showed that more than half of university students in Saudi Arabia (medical and non-medical specialties) had good knowledge of first aid, possibly correlating to higher education [20].
This study showed that most participants had good attitudes toward the importance of first aid, who should know it, and its role in reducing casualties' morbidities. Less than half of the participants changed their view of providing first aid for fear of infection during the COVID-19 pandemic. Regarding practice, more than three quarters of participants reported they would help an ill or injured person, but a lack of knowledge, fear of legal responsibility, and fear of infection with COVID-19 were barriers.

CONCLUSION
Despite the promising high motivation and readiness to attain knowledge of first aid, public awareness and knowledge regarding first aid were very low among the community of the Makkah region. Furthermore, although attitudes were very good, practice was restricted by some barriers, including poor knowledge, fear of legal responsibilities, and the COVID-19 pandemic. Most people need to attend first aid courses, but the inaccessibility of these events to the public and scheduling issues were the most common barriers to applying, especially through campaigns. We recommend a national strategy to implement regular first aid courses and campaigns for the public, using demonstration manikins. CPR should also be included in high school programs because this could introduce significant support for the community.

CONSENT
As per international standard or university standard, respondents' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
Ethical approval was obtained from Directorate of Health Affairs -Taif, Research and Studies Department by the number of 566 at 02/06/2021.