Knowledge and awareness of paediatric basic life support among parents in the Lady Ridgeway Hospital for Children, Colombo, Sri Lanka

Background: Out-of-hospital cardiac arrest in children is uncommon but significant, with poor survival rates and high morbidity. Choking in children is common but less reported with high mortality. Early commencement of cardiopulmonary resuscitation (CPR) in cardiac arrest or following of choking algorithm in a case of choking is important for survival of the victim. Objectives: To survey the knowledge, awareness and attitudes of parents in Sri Lanka regarding paediatric Basic Life Support (BLS) including early treatment of choking. Method: This was a descriptive cross-sectional study and questionnaires were administered to parents of children managed at the Preliminary Care Unit (PCU) and wards 2 and 4 of Lady Ridgeway Hospital, Colombo from October 2022 to January 2023. Sample size was calculated according to the Lwanga and Lemeshow method. Total respondents were 350 out of total participants of 415. The questionnaire consisted of four sections for assessment of demography, knowledge and attitude. Total scores of each aspect were analysed with respect to different factors. Results: Of the participants, 95% did not have BLS training and the largest proportion of them was educated only up to the General Certificate of Education (GCE) ordinary level. Knowledge of specific aspects of BLS or choking was demonstrated by only about 10% of the population. Nearly 50% of parents had identified substandard common practices as correct methods. There was no statistically significant correlation between total score of each aspect and previous observations, training or highest educational level. It was assessed with 95% confidence interval. However, seeing BLS had improved knowledge of basic health (p=0.013). Conclusions: Seeing the procedure on television or other resources had not improved knowledge of BLS. Workshops were the


Introduction
Out-of-hospital cardiac arrest (OHCA) in children is rare but significant, with poor survival rates and high morbidity 1 .Asystole is the most common dysrhythmia 1 .Paediatric basic life support (BLS) is the initial resuscitation in a child with cardiac arrest or choking which should be initiated immediately, even outside the hospital, until advanced life support is initiated 2 .Some of the techniques are different depending on the size of the child, particularly between infants and older children 2 .As far as the causes of cardiac arrest are concerned, respiratory failure is the commonest cause in newborns, whereas sudden infant death syndrome, respiratory diseases, airway obstruction (including foreign-body aspiration), submersion, sepsis, and neurological disease are the leading causes in infants 3 .Beyond 1 year of age, injuries are the leading cause of death 3 .Overall, respiratory failure is the commonest cause of cardiac arrest in children 3 .Thus, effective breathing should be delivered by correct technique to achieve successful resuscitation 3 .
The sequence of BLS in cardiac arrest is D: out of danger, R: check response, S: shout for help, A: check and open the airway, B: give 2 rescue breaths, C: chest compression and D: defibrillation 2 .In an out-of-hospital environment, the rescuer should not become a second victim; therefore, the child should be removed from continuing danger as quickly as possible 2,3 .Following that, the rescuer should check the response with stimulation by tapping.If the child does not respond, the airway should be assessed using the look, listen, and feel technique 2,3 .As soon as it is identified that the child is not responding, the rescuer should call for help either by shouting or dialing 1990 for an emergency ambulance (available in Sri Lanka) 2,3,4 .Then, 2 rescue breaths should be given immediately using the mouth-to-mouth breathing method, unless a specific mask is available 2,3 .A pulse check is not an essential element and may be a difficult task for a lay rescuer to perform.Once effective breathing is present, which is evident by chest expansion, chest compression should be started with a compression-to-breathing ratio of 15:2 2,3 .Ideally, a child's head should be positioned in neutral and sniffing positions for infants and older children, respectively 2,3 .This sequence should be followed in the case of an unresponsive child 2 .
Choking is the mechanical obstruction of the internal airways (pharynx, hypopharynx, trachea) by a foreign body causing respiratory failure and it is a type of asphyxia 5 .According to a study by Loenzoni G, et al 6 , it is a major cause of death in children, and 60-80% deaths following choking are due to food.Anatomical and physiological characteristics specific to young children are thought to be the reason for increased choking among them while eating 5 .Choking can cause death within minutes, and prompt intervention, using the BLS choking protocol, is required to save the victim's life 2,3,5 .
The first crucial step in the BLS choking protocol is to identify whether the victim has an effective cough or is in cardiac arrest 2,3 .A conscious older child should be encouraged to cough if there is an effective cough 2,3 .If acute stridor develops or child does not have an effective cough, the foreign body should be dislodged immediately using back blows and chest thrusts 2,3 .Combining manoeuvres give better results than doing them individually 2,3,5 .However, if child becomes unresponsive with features of cardiac arrest, cardiopulmonary resuscitation (CPR) should be started immediately 2,3 .
OHCA in infants or toddlers mainly occurs at home 7 .A family member is usually the first responder available at the time of the incident 7,8 .Asystole is the predominant arrhythmia, which indicates effective CPR 3 .In children, early, effective bystander CPR has been associated with the successful return of spontaneous circulation and neurologically intact survival 2,3,9,10,11 .BLS courses should be offered to target populations such as expectant parents, childcare providers, teachers, sports supervisors, and others who regularly care for children.To implement steps to improve knowledge and practices in BLS, it is essential to identify the current knowledge, practice, and attitude in BLS.Further, knowing the possible obstacles to improving knowledge and practice, and the factors associated with inadequate or adequate knowledge are also crucial.

Inclusion and exclusion criteria:
All parents or guardians that brought their children to PCU and wards 2 and 4 of LRH for any form of assessment, investigation, or treatment were enrolled.Parents or guardians unable to read, understand and write any of the three languages (Sinhala, Tamil, English) were excluded.

Sample size and method:
This was 415, calculated using the Lwanga and Lemeshow method.Patient management was not affected by filling out the questionnaire, as it was performed only during spare time.A questionnaire was distributed among 10 parents before commencing the survey, and none of the participants indicated that the questions were incomprehensible.The questionnaire was developed in Sinhala, Tamil and English, the three languages used in Sri Lanka.A convenient sampling technique was used.
To cater to participants with a lower educational level, simple words were used, and the questions and answers were tailored to be short, straightforward, and to the point.Pictograms were also made available so as to reduce potential confusion among participants.
The questionnaire consisted of four sections.Section A focused on the demographic profiling of the participants.Those who had previously attended a BLS course were denoted as 'trained', while those who had no prior attendance were denoted as 'untrained'.Section B focused on awareness of BLS or choking, including the method by which they have observed it.Section C comprised questions assessing knowledge of basic health, BLS, and choking; only those who had seen BLS performed were included in the assessment of knowledge on BLS, and only those who had seen an initial treatment for choking were included in the assessment of knowledge on initial treatment for choking; however, all respondents were included in the analysis of data of knowledge on basic health.Section D focused on attitudes toward the need for training in BLS, and responses from all individuals were included in the analysis.In Section C, responses were based on Advanced Paediatric Life Support 2016 2 .There were single-correct-response questions and multiplecorrect-response questions in both BLS and choking parts.A correct answer to each question was awarded a score of one.There was a question (Q11) on the correct sequence of the BLS algorithm following cardiac arrest.Three appropriate correct orders were developed, and any other order was considered incorrect, while incomplete or blank ones were taken as 'invalid'.Subsequently, knowledge on each part, i.e., knowledge on basic health, knowledge on BLS, and knowledge on the choking algorithm, was expressed as a total score for each part.
Ethical issues: There were no confidentiality issues because personal data was not required in the questionnaire.Ethical clearance was obtained from the Ethics Review Committee (ERC) of the Faculty of Medicine, University of Colombo (Ref.EC-22-110) on 20 th October 2022 before the commencement of the research.

Statistical analysis:
The data were analysed using the Statistical Package for Social Sciences (SPSS) for Windows version 26.Means were assessed for demographic data, and some of them were presented as graphs.The means of qualitative data were compared using Chi-square test, whereas those of qualitative and quantitative data were compared using the independentsample t-test.A p-value less than 0.05 was considered statistically significant.

Results
Questionnaires were distributed among 410 parents but only 350 responded during the given period.Of the participants 322 (92%) were females.Only 17 (5%) respondents had participated in any form of BLS training.Eleven participants mentioned that they underwent training between 2005 and 2014.Figure 1 shows the distribution of the study participants.Table 1 shows the responses to the questions on basic health.More than 80% of participants responded correctly to the first two questions.Only 33% knew that the brain cannot survive more than 5 minutes without a blood supply.Total scores (TS) of basic health, BLS, and the choking algorithm were calculated and compared to different variables to assess their correlation with the 95% confidence interval as demonstrated in Table 6.The TS of basic health had to vary between 0 and 3 among participants (n=350).It was compared with training status, observation status of BLS or choking treatment, and the highest educational level.A mean score of 1.95 was obtained in the group of those who had seen BLS (p=0.013).However, none of the other variables showed a statistically significant correlation (p>0.05).TS on BLS had to be between 0 and 14 among those who had observed BLS earlier (n=216).However, there was no statistically significant correlation between TS-BLS and BLS training status or the highest educational level.TS on the choking algorithm had to be between 0 and 4 among those who had observed initial treatment of choking (n=225).Correlation assessment revealed that there was also no statistically significant correlation between TS on choking and BLS training status or highest educational level.

Discussion
This research was intended to identify knowledge and awareness of paediatric BLS and choking algorithms and attitudes toward them.This was assessed among parents of children who presented to the PCU and were admitted to Wards 2 and 4. It was assumed that this sample represents parents in the whole country because this is the leading children's hospital in Sri Lanka, where children are referred to this centre from all over the country for different reasons due to the availability of sub-specialties.There was no previous research evidence on knowledge of BLS in parents in Sri Lanka, and it is important to identify gaps in knowledge of BLS (including the choking algorithm) and factors that might help to improve BLS knowledge in parents.Overall, the research results revealed that parents had inadequate knowledge of BLS, choking, or basic health, irrespective of their educational level.However, they had optimistic attitudes toward the need for BLS training in the future.
Most parents could answer some correct facts on basic health (physiology), even though they could not differentiate correct responses, which are numerical (i.e., duration in minutes), from incorrect responses.This answering pattern was observed in the assessment of knowledge on BLS and the choking algorithm as well.Awareness of the important facts, such as, brain survival without oxygen is very short-lasting, was lacking among parents.Common but substantial practices were also included in the responses to check their true knowledge.Parents responded to them as correct ones, such as applying water to wake up an unconscious child or putting the child upside down in choking.Nearly 10% of parents had precise knowledge such as chest compression rate, compression to ventilation ratio, and giving abdominal thrust in choking, which could not be guessed without proper background knowledge.According to the assessment of possible factors that might affect the knowledge of basic health, BLS, or the choking algorithm, only the knowledge of basic health would have been greater if they had seen BLS previously.Otherwise, previous training, observation of the BLS or choking algorithm, and their highest educational level did not correlate with their knowledge of the above three aspects.If proper training had been followed, their knowledge of those aspects should have been improved by their training.Thus, it is rational to argue about the quality of those training programmes.Most participants had seen them on television, and therefore, it can be concluded that this source of education had not been effective for the people.
Research to identify knowledge and awareness among parents regarding BLS in Sri Lanka is scanty.However, several studies have been conducted to assess knowledge and practices in first aid for injuries or emergencies in children 12,13,14,15 .Some studies have identified knowledge of basic and advanced life support among healthcare workers and medical and nursing students 16,17,18,19 .Edirisinghe NK, et al 19 studied the knowledge of emergencies such as choking, burns, and acute poisoning and their first aid practices among mothers of children admitted to paediatric wards in District General Hospital Kalutara; only 11% had adequate knowledge of first aid for choking.Balasuriya A, et al 15 studied the prevalence of home accidents among children aged 1-4 years, and its relationship with the knowledge, attitude, and first aid practices of mothers in the Bulathsinghala MOH area; this study showed that 64% had adequate knowledge of first aid for choking 15 .Alahakoon P, et al 12 studied the knowledge and attitude toward first aid among advancedlevel students in Gampaha District; they found that educational qualifications related to biology have improved the knowledge of first aid but that previous training status had not affected the knowledge of first aid.Ralapanawa D, et al 17 demonstrated that overall knowledge and attitudes toward advanced life support, in nearly 10% of final-year medical students and medical officers in Peradeniya Teaching Hospital was inadequate.Thoradeniya V, et al 16 studied knowledge of BLS among nursing students and found that only 50% had good knowledge and attitude towards BLS.Alukumbura D, et al 18 showed that knowledge and attitude on BLS among traffic police officers in Nugegoda was inadequate.However, none of the studies had evaluated the knowledge, including techniques on paediatric BLS and choking, among parents.
A study on knowledge, attitude, and perception of infant BLS, conducted in Singapore by Chia P, et al 1 revealed that those who had participated in the BLS course had better knowledge and that those who had higher educational qualifications demonstrated better knowledge.Uehara R, et al 20 studied the associations of poor knowledge of cardio-pulmonary resuscitation among parents in Japan; age of mother at delivery, awareness of medical facilities for emergency services at night or during the weekend, current occupational status of mother and current economic status, were independently associated with CPR awareness.A study in India by Pathak A, et al 8 revealed different modes of transport in an emergency and different first aid practices in India; only 1% of the injured used ambulance services, while motorbikes were the most preferred mode of transport; it revealed potentially harmful practices used as first aid in India.A study by Pai M, et al 21 revealed that knowledge of BLS improved more by 'hands-on training' compared to educational videos, among 458 school adolescents in India.
People identify BLS as a life-saving procedure and are willing to participate in a workshop.Even though they have seen either BLS or choking management on television, they still prefer to participate in a workshop as they identify it as a skill that needs to be practised.
Previous research to identify knowledge of first aid among parents or students performed in Sri Lanka had not identified knowledge and practices related to BLS.Therefore, with this research, we have statistics on parents' knowledge of that aspect.Not only that but this data could also be utilized to organize workshops to enhance parents' knowledge of BLS, including the choking algorithm.Parents are the first responders in an emergency for their children.Widespread standard BLS workshops should be implemented for parents, irrespective of their educational level, to enhance their knowledge.

Conclusions
Seeing the procedure on television or other resources had not improved knowledge of BLS.Workshops were the preferred method to improve their knowledge on BLS including the choking algorithm and participants' educational level was not important in organizing such an event.

Figure 2
Figure 2 demonstrates the distribution of the highest educational level of participants.Most participants were educated only up to General Certificate of Education (GCE) ordinary level.

Table 3
demonstrates the distributive data of correct answers to the questions on BLS.It revealed that only 2.8% had an idea about the correct order of steps to follow in a cardiac arrest; 16-57% knew how to identify cardiac arrest early; 16-36% of participants knew the correct way to wake up an unconscious child, while 80% identified the application of water, which is a substandard common practice in Sri Lanka, as another way to do it.Only 50% knew the correct site of chest compression, while 40% knew the correct depth.However, most individuals did not know the correct rate of chest compression; the majority believed it to be 50 beats per minute, while only 10% knew the correct rate.Majority knew how to confirm the child was not breathing.Only 11% knew the correct ratio of chest compression to breathing, while 44% believed it was 3:1.Most of that sample (78.2%) incorrectly responded to the question "Chest compression to mouth-to mouth breathing ratio should be:" as 3:1.

Table 4 : Correct responses to the questions on initial management of choking Question Correct response No. of correct responses (n=225)
As demonstrated in Table5, 45% of participants preferred workshops to learn BLS; 84% are willing to participate in such a workshop, while the majority of those who are not willing to do so mentioned time constraints as a barrier.Approximately 93% of people believed that BLS was important to save lives.