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Ministry of Higher Education
and Scientific Research
University of Kufa
Faculty of Nursing
Knowledge and Attitudes of Primary School Teachers
Toward First Aid in Al-Najaf Al-Ashraf City
A thesis Submitted to the Council of Faculty of Nursing at
University of Kufa in Partial Fulfillment of the Requirements for
the Degree of Master in Nursing Science / Community Health
Nursing Department
By
Hussein Mansour Ali Al-Tameemi
Supervised by
Asst. Prof. Fatima Wanas Khudair
B.Sc., MSc., PhD in Community Health Nursing
September 2016 A.D. Dhu al-Qi'dah 1437 A.H.
ِ‫م‬‫ي‬ِ‫ح‬َّ‫الر‬ ِ‫ن‬َْ‫ْح‬َّ‫الر‬ ِ
‫ه‬‫اّلل‬ ِ‫م‬ْ‫س‬ِ‫ب‬
﴿‫ا‬ً‫يع‬َِ‫َج‬ َ‫َّاس‬‫ن‬‫ال‬ ‫ا‬َ‫ي‬ْ‫َح‬‫أ‬ ‫ا‬ََّ‫َّن‬َ‫أ‬َ‫ك‬َ‫ف‬ ‫ا‬َ‫اه‬َ‫ي‬ْ‫َح‬‫أ‬ ْ‫ن‬َ‫م‬َ‫و‬﴾
‫العظيم‬ ‫العلي‬ ‫هللا‬ ‫صدق‬
/‫املائدة‬ ‫{سورة‬‫اآلية‬ ‫من‬ ‫جزء‬32}
‫الما‬
‫ئدة‬
Supervisor Certification
I certify that this thesis, which entitled (Knowledge and Attitudes
of Primary School Teachers Toward First Aid in Al-Najaf Al-Ashraf City),
was prepared under my supervision at the faculty of Nursing, University of
Kufa in partial fulfillment of the requirements for the degree of Master in
Nursing Science.
Supervisor
Dr. Fatima Wanas Khudair
Asst. Professor and Academic Advisor
Faculty of Nursing
University of Kufa
/ / 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Dedication
TO
My father and mother with all love and
respect.
My wife and family with all love and
respect.
My advisor (Dr.Fatima Wanas Khudair)
with all my respect.
My dear friends with my love and
respect.
Primary school teachers who accepted to
participant in the study.
Hussein
I
First of all, great thanks for Allah the most merciful the most
compassionate, and the prayer and peace of Allah be upon our Master
and prophet Muhammad and his divine good family, who guided us to
get out of darkness of nescience.
Numerous people have helped and supported me in my
endeavors. Most especially, I wish to express my deepest and grateful thanks to
my supervisor Ass. Professor Dr. Fatima Wanas Khudair, the head of
Community Health Nursing branch in the Faculty of Nursing, University of
Kufa.
I gratefully acknowledge the endless generosity of the experts who kept
me on the right track for their time and expertise in reviewing and evaluating
of study instrument.
I offer my thanks and appreciation to the Directory of Education of Al-
Najaf Al-Ashraf, school principals and school teachers for their collaboration
during the current study.
Also, I would like to recognize the positive efforts and invaluable
assistance of the library staff in the Faculty of Nursing.
Furthermore, my enduring gratitude goes to my father and mother for
their unfailing encouragement, patience, and love.
Finally, special thanks to my dear wife, who was a great supporter for
me during the most difficult circumstances that I faced, and a great tribute to
my kids who were disturbing me during writing this thesis.
Acknowledgments
II
Abstract
Background: Unintentional injuries as well as sudden sicknesses is
one of the important noteworthy reasons that lead to impairments and
mortality in children, particularly those who are in school age. From this
standpoint, primary school teachers’ knowledge about first aid is necessary
in order to be prepared for providing first aid when needed for children
during school time.
Methodology: a descriptive cross-sectional study was applied on
teachers of governmental primary schools in Al-Najaf city. Furthermore; the
study continued from 1st
November 2015 to 4th
September 2016, in order to
assess participants' knowledge and their attitudes toward first aid, as well as,
to find any significant relation for teachers socio-demographic characteristic
with their knowledge and attitude regarding first aid.
By using a simple random sampling, thirty governmental primary
schools were selected randomly, and then 320 primary school teachers were
selected randomly, through an equation used for determining sample size;
finally, the total number of valid questionnaires for analysis were 302.
A questionnaire composed of three parts was used, the first part
included inquiry regarding socio-demographic characteristic of participants,
and the second part included questions concerning knowledge about first aid
which was divided into six domains, while the last part included questions
regarding teachers' attitudes toward first aid and also it was sub-divided into
three domains.
Results: The result showed that from total 302 school teachers
included in the study, 287 (95%) of them had total fair knowledge and only
15 (5%) of participant teachers had poor knowledge, besides no one of them
had good knowledge. With regard to teachers' attitudes towards first aid, the
results showed that 282 (93.4%) of the teachers commonly had a positive
III
attitude toward first aid, while the number of those who owned the negative
attitudes towards the first aid did not exceed twenty teachers, about (6.6%)
of participants.
With respect to the relation of participants’ socio-demographic data
with their knowledge levels no significant association was determined but
for monthly income, while concerning teachers’ attitudes toward first aid
only residency in urban areas and years of experience demonstrated
significant relation to their socio-demographic data.
Conclusions and Recommendations: the final conclusion and
summary of the study showed unsatisfactory knowledge about first aid
among teachers, while, participants generally expressed positive attitudes
toward first aid. Therefore, the researcher recommended to establish a
compulsory training sessions for teachers at the beginning of each academic
year.
IV
List of Contents
Subject
Page
No.
Acknowledgements І
Abstract ІІ-III
List of Contents IV-V
List of Tables VI
List of Figures VII
List of Abbreviations VIII-IX
Chapter One: Introduction 1-7
1.1 Background 2-3
1.2 Importance of the Study 4-5
1.3 Statement of the Problem 6
1.4 Objectives of the Study 6
1.5 Definition of the Terms 6-7
Chapter Two: Review of Literatures 8-48
2. Summary for Review of Literature 9
2.1. Section A (Historical Overview): 10-12
2.2. Section B (Literatures Regarding General Information about
First Aid):
12-21
2.3. Section C (Literatures Regarding Wounds and Bleeding): 22-27
2.4. Section D (Literatures Regarding Bone and Joint Injuries): 27-32
2.5. Section E (Medical Emergencies and Illnesses): 32-41
2.6. Section F (Literatures Regarding Burns): 41-44
2.7. Section G (Literatures Regarding Bites, Foreign Bodies and
Stings):
44-47
2.8. Section K (Literatures Regarding Attitude): 47-48
Chapter Three: Methodology 49-56
3.1. Study Design: 50
3.2. Administrative Arrangements: 50
3.3. Ethical Consideration: 50
3.4. Setting of the Study: 50
3.5. The Sample of the Study: 51
3.5.1. The Sample Size: 51
3.5.2. The Sampling of the Study: 51-52
3.6. Instrument of the Study: 52
3.7. Current Study Validity: 52
3.8. Pilot Study: 53
3.9. Reliability: 53
V
3.10. Data Collection: 53-54
3.11. The Statistical Analysis: 54-56
Chapter Four: Results of the Study 57-77
Chapter Five: Discussion of the Study 78-92
5.1. Socio-Demographic Characteristic and Educational Level of
Participants:
79-81
5.2. Previous Information on First Aid Among Participants: 81-84
5.3. General Information of Primary School Teachers about First
Aid:
84-85
5.4. Teachers’ Knowledge about First Aid for Wounds and
Bleeding:
85
5.5. Teachers’ Knowledge about First Aid for Bone and Joint
Injuries:
85-86
5.6. Teachers’ Knowledge about First Aid for Medical Conditions: 86-88
5.7. Teachers’ Knowledge about First Aid for Burns: 88
5.8. Teachers’ Knowledge about First Aid for Foreign Bodies
(Eyes & Ears), Dog’s Bite and Stings:
88-89
5.9. Teachers’ Overall Knowledge about First Aid: 89-90
5.10. Primary School Teachers’ Attitude Toward First: 90-91
5.11. The Relationship Between Participants’ Overall Knowledge
and Attitude Toward First Aid and Their Socio-Demographic
Characteristic:
92
Chapter Six: Conclusions and Recommendations 93-96
6.1 Conclusions 94
6.2 Recommendations 94-95
References 96-122
Appendices No.
Panel of Experts A
Administrative Arrangements B
Ethical Considerations C
Linguists Certification D
Questionnaire in Arabic E
Abstract In Arabic
VI
List of Tables
Table
No
Table Title Page
3.1 Reliability of the current study instrument 53
4.1 Socio-demographic characteristics of the studied group 58
4.2 Educational level and years of experience of the studied
group
59
4.3 Distribution of Previous and source of Information about first
aid
60
4.4 Responses of participants regarding the general information
about first aid
61
4.5 Responses of participants regarding the first aid of Wounds
and Bleeding
63
4.6 Responses of participants regarding the first aid of Bone and
joint injuries
65
4.7 Responses of participants regarding the first aid of medical
situations
67
4.8 Responses of participants regarding the first aid of Burns 69
4.9 Responses of participants regarding the first aid of bites,
stings & foreign body
71
4.10 Evaluation of teachers’ overall knowledge about first aid in
school
72
4.11 Relationship between overall knowledge of participants and
their socio-demographic characteristics
73
4.12 Responses of participant teachers to questions on attitude
toward first aid
74
4.13 Frequency distribution of domains and overall attitude toward
first aid of participant teachers
75
4.14 Relationship between attitude of participants toward first aid
in schools and their socio-demographic characteristics
77
VII
List of Figures
Table
No
Title of Figure Page
2.1 Priority of Treatment. 15
2.2 First Aid for Nosebleeds. 26
2.3 Types of fractures. 29
2.4.A Fixing with splint only. 31
2.4.B Fixing with both splint and sling. 31
4.1 Distribution of participant teachers according to their
knowledge on general information on first aid.
62
4.2 Distribution of participant teachers according to their
knowledge on first aids for wounds and bleeding.
64
4.3 Distribution of participant teachers according to their
knowledge on first aids for bone and joints injuries.
66
4.4 Distribution of participant teachers according to their
knowledge on first aids of medical situations.
68
4.5 Distribution of participant teachers according to their
knowledge on first aids of burns.
70
4.6 Distribution of participant teachers according to their
knowledge on first aids for bites, stings & foreign bodies.
72
4.7 Distribution of participant teachers according to their
attitude toward first aids in schools.
75
VIII
List of Abbreviations
Abbreviation Meaning
AAP American Academy of Pediatrics
ACEP American College of Emergency Physicians
AD Anno Domini
AHA American Heart Association
AIDS Auto Immune Deficiency Syndrome
ANRCS American National Red Cross Society
BBB Breathing, Bleeding and Bones
BC Before Christ
BSL Basic Life Support
CD Compact Disk
CDC Centers for Disease Control and Prevention
CPR Cardio Pulmonary Resuscitation
CSO Central Statistical Organization
d Level of Significance or Desired Precision
D.M Diabetes Mellitus
e.g. exempli gratia (Latin Words that Means for example)
IQD Iraqi Dinar
NCPP National Committee for Population Policies
NSC National Safety Council
P Estimated Proportion
P Page
P.P Pages
P.value Probability Value
q One Minus estimated proportion
RICE Rest, Ice, Compression and Evaluation
SPSS Statistical Package for the Social Sciences
IX
TV Television
U.K United Kingdom
USA United States of America
WHO World Health Organization
X, 30 Chapter Number from Bible
Z Level of Confidence
Chapter One
Introduction
Chapter One: Introduction 2
Chapter One
Introduction
1.1. Background:
Injuries and sudden illnesses are an essential issue in public health and
usually occurring at any times of daily life. Besides, school children injuries
take a major part. Unintentional playground injuries occurring during school
hours and includes falls, head injuries, wound bleeding and others (Salminen
et al., 2014). Accidental injuries are usually categorized based on their
happening, for instance: burns, scalds, poisoning, falls and drowning,…etc.
(WHO, 2010). They are also exposed to numerous kinds of epidemiological
factors in the school which impact their current and upcoming condition of
health (Masih et al., 2014).
The first aid is an urgent attention delivered to victims of sudden
illness or injury until medical helps arrive. So that, early treatment of such
emergencies decreases morbidity and deaths among school aged children
(Singer et al., 2004; Abdella et al., 2015; Khatatbeh, 2016).
A significant part of children’s life is school lifetime, which directly
affect their physical and mental health(Thyer, 1996; Olympia et al., 2005).
Unfortunately, school health services are ignored in some countries
particularly the developing ones. This contributes to shortage in awareness
and knowledge regarding sudden illnesses and first aid measures (Bhatia et
al., 2009). Children's times mostly spend in school under direct supervision
of teachers. Consequently, first-aid should be well-known by teachers who
are the key personnel to deal with urgent health needs during school hours.
Healthy harmless environment is very vital to avoid these hazards besides
competent teachers who can identify any health problem and able to provide
first aid for commonly happening emergencies in school (Masih et al., 2014).
The 2005 guidelines for first aid definition is “the assessment and
interventions that can be performed by a bystander (or by the victim)
Chapter One: Introduction 3
immediately with minimal or no medical equipment.” (AHA (American
Heart Association ) and ANRCS (American National Red Cross Society),
2005). Another definition adopted in 2014 by American College of
Emergency Physicians (ACEP), which refers to first aid as the actions taken
in response to somebody who is wounded or has unexpectedly become ill
(Piazza, 2014). The primary purpose of first-aid is to reduce suffering, make
healing process possible and decrease damage. So that, the first action taken
to deal with injuries and sudden illnesses decides the upcoming sequences
of illness and complication rates (Goel and Singh, 2008).
The National First-aid Science Advisory Board clarified, everybody
can and must learn first-aid, i.e. education and training in first-aid should be
worldwide. This is recognized by the fact that correctly directed first-aid
means the difference among life and death, early versus late rescue, and
momentary versus long-lasting disability (Lingard, 2002; Singer et al., 2004;
The National First-Aid Advisory Board, 2005). Therefore, teachers must
know the basic rules for first aid as well as the students must be instructed
on first aid (Uskun et al., 2008; Celik, 2013; Sönmez et al., 2014).
Identification of urgent situation and calling for help is an important
issue in first aid, particularly in case of lack or insufficient basic knowledge
about first aid measures for complex situations to be sure that the child will
have a professional medical help (Mahony et al., 2008; Cowan et al., 2010).
Teachers are almost the first and the main caregiver represented the
first line to protect school children, in addition, teachers’ role complements
the parent’s role. School teachers during the school hours, are the real first-
respondent to emergencies, injuries resulting from school accidents.
Therefore, they have to be capable to act accurately with health emergencies
affected the school children (Barrett, 2001; Uskun et al., 2008; Sönmez et
al., 2014).
Consequently, the current study tried to assess the knowledge and
attitude of group of Iraqi primary school teachers in Al-Najaf city.
Chapter One: Introduction 4
1.2. Importance of the Study:
Unintentional injuries encountered in the childhood are a global public
health problem and are to be found as a first order among the causes of
mortality and morbidity. Across the world, at least 875 000 children aged
below 18 years decease due to unintentional injuries yearly and more than
95% of these deaths happen in countries with low and middle income levels
(WHO, 2006; Altunda and Öztürk, 2007; İnanç et al., 2008). For example,
in United States of America each year 200,000 schoolchildren are injured
during playing and 70% of cases requires hospitalization, moreover, in
Europe countries as Poland there were 3274 school accidents reported
among 293,000 primary school student every year (Sosnowska and Kostka,
2003; Al-Robaiaay, 2013).
Not only injuries but, chronic childhood illnesses may become
suddenly an emergency during school period. Schools today contains higher
numbers of children with long-lasting and severe illnesses, suffering from
diseases like epilepsy, asthma and diabetes mellitus which are requiring
special attention and urgent care (Bergren, 2010; Allen et al., 2012).
Asthma considered as very public respiratory disorder distressing
school children. WHO has reported that worldwide, around 235 million
people are asthmatic (Govender and Gray, 2012). Depending on Centers for
Disease Control and Prevention (CDC) ten percent of children at USA
schools having asthma, while in south Africa asthma affects 20% of
schoolchildren (Bergren, 2013; Govender & Gray, 2012). Many researchers
recognized impact of teachers’ knowledge on care for asthmatic children. In
USA, inappropriate actions of schoolteachers maybe had an essential part in
the mortality of school children with asthma between 1990-2003. (Tse, 2002;
Greiling et al., 2005; Ones et al., 2006; Govender and Gray, 2012).
In addition, diabetes mellitus is another chronic disease affecting
children and juveniles, and requires continuous monitoring of affected
Chapter One: Introduction 5
children and the teachers can play an important role this case (Aycan et al.,
2012; Bergren, 2013).
Likewise, epilepsy is one of most commonly neurological childhood
problems, mostly observed in first decade of life. Worldwide, there are 33
million child suffering from epilepsy. The intense consequence of having
seizure in school can be very hurtful for any child and requires teachers’ first
aid knowledge to deal with (Jacoby, 2002; Bishop and Boag, 2006; Aydemir,
2008; Karimi and Heidari, 2015).
School children are more susceptible to injuries and carry a greater
risk due to developmental and behavioral characteristic including
unawareness of hazards and being active as well as bodily properties
including narrower airways, smaller body mass and thinner and extra
susceptible skin (Peden, 2008).
Global studies have noted a diverse depiction around readiness among
school teachers to apply first aid. In European studies , for instance, the
current philosophy is tending to learn first aid to primary school teachers and
they will in turn transfer such skills and knowledge to their pupils , besides,
poor knowledge, attitude, practice and awareness among school teachers was
observed by many Asian researchers (Bollig et al., 2009; Al-Robaiaay, 2013;
Devashish et al., 2013; Kumar et al., 2013; Ammirati et al., 2014).
There is a lack in scientifically sound data and only few studies are
concerned with this subject in Iraq, in addition, physicians and health care
providers are not present in the school (Al-Robaiaay, 2013).
Therefore, the assessment of knowledge and attitude of primary
schoolteachers and their information regarding first aid will help in
establishment of educational programs and workshops about the first aid,
that resulting in development of their knowledge and attitude toward first aid
with intern reduction in the risk of injuries and enhance life saving for
primary school aged children.
Chapter One: Introduction 6
1.3. Statement of the Problem:
Knowledge and attitudes of primary school teachers toward first aid
at Al-Najaf City.
1.4. Objectives of the Study:
1-To assess the level of knowledge and attitude of primary school
teachers toward first aid at primary schools of Al-Najaf city.
2- To identify the relationship between the level of knowledge and
attitudes of primary school teachers toward first aid and their
sociodemographic characteristic (age, gender, residency, marital status,
number of children, monthly income, educational level, years of experience,
previous information about first aid and sources of previous information).
1.5. Definition of Terms:
1.5.1. Knowledge:
a. Theoretical Definition:
Information gained through experience or education (Muneeswari,
2014).
b. Operational Definition:
In this study, the knowledge refers to the ability of teachers to answer
the questions correctly and will be measured through self-administered
questionnaire.
1.5.2. Attitude:
a. Theoretical Definition:
The 2015 American Psychological Association dictionary of
psychology defined attitude as “a somewhat permanent and overall
evaluation of an object, person, group, issue, or concept on a distance
ranging from negative to positive”. Attitudes delivers synopsis judgments of
target objects which are supposed to be resultant from precise beliefs,
feelings, and previous actions accompanied through those objects
(VandenBos, 2015). In another words, “attitudes are evaluative reactions
Chapter One: Introduction 7
(positive or negative) toward objects, events, and other people” (Griggs,
2012).
b. Operational Definition:
In this study attitudes recognized in the light of responses of primary
school teachers to self-administered questionnaire of five degree Likert scale
with taking into account positive and negative formed questions.
1.5.3. Primary School Teacher:
a. Theoretical Definition:
Primary school teacher is a person who teaches pupils (children under
13 years of age) at the elementary school (Collins English Dictionary, 2016;
Merriam-Webster’s Learner’s Dictionary, 2016).
b. Operational Definition:
Primary school teachers who are existed in primary schools of Al-
Najaf city during the period of the study, which they are graduated from
teachers' preparation institutes and colleges and working in primary schools
in the field of education.
1.5.4. First Aid:
a. Theoretical Definition:
Emergency measures to help an ill or wounded person preceding to
obtaining skillful medical care (Marcovitch, 2009), or in another terms it is
“immediate care given to an injured or suddenly ill person, and includes
providing momentary help while waiting for competent medical attention, if
needed is obtained or until the chance for recovery without medical care is
assured” (Thygerson et al., 2011).
b. Operational Definition:
In the current study, first aid means knowing about injuries requiring
initial interventions such as wounds, bleedings, epistaxis, fractures, burns, or
electrical shocks, or about sudden illnesses such as epileptic fits, diabetes
emergency or asthma attack, and other incidental matters such as dog bites
or bug stings, etc.
Chapter Two
Review
of literature
Chapter Two: Review of Literature 9
Chapter two
Review of Literature
Review of literature is an essential step in research process. It refers
to a widespread, exhaustive and systematic examination of different
publications related to study issue.
Review of literature, is originated from many sources such as books,
manuals, previous thesis, dissertation, journal articles, encyclopedias,
reports, internet…etc.(Nieswiadomy, 2012). The most vital aim for
conducting review of the literature is to identifying any topics known
regarding the current study, whereas any former studies are located, and the
conceptual framework of the study is formulated. Besides, review of
literature is beneficial in planning the methodology of study (Nieswiadomy,
2012).
In the current study, review of literature was collected and conducted
according to the following:
2.1. Section A: Historical Overview.
2.2. Section B: Literatures regarding general information about first aid.
2.3. Section C: Literatures regarding wounds and bleeding.
2.4. Section D: literatures regarding bone injuries.
2.5. Section E: literatures regarding other medical emergencies and illnesses.
2.6. Section F: literatures regarding burns.
2.7. Section G: literatures regarding bites, foreign bodies and stings.
2.8. Section K: literatures regarding attitude.
Additionally, each of aforementioned sections contained a brief
historical and epidemiological summary for the relevant subject, besides, a
sufficient information on topics of each section and related first aid actions.
Furthermore, each section was ended by revealing some previous studies
which are related to the heading of section.
Chapter Two: Review of Literature 10
2.1. Section A (Historical Overview):
First aid skills and expertise as it known today, were recognized back
in history but more simply, particularly during warfare (Pearn, 1994).There
are many evidence and clues across the ancient civilizations about simple
skills used to help injured people instantaneously especially by militaries.
For example, a scene painted on a traditional Greek pottery believed to be
from 500 years BC, shows the greatest Grecian warrior Achilles from Greek
mythology applying bandage to his injured escort Patroclus during the siege
of Troy which is an early example for providing first aid without organized
medical support (Cotterell, 1996). As further evidence during the bronze age
in the middle east, the gospel of St Luke (x, 30) memorialized the good
Samaritan ethical values of assisting persons and efficiency of bandaging
injured people (Pearn, 1994).
Decreasing morbidity and death by applying early first aid, during
wars were a big concern for many ancient militaries. The Roman military
had the most successful experience for emergency medical services to
support their legions, especially under the role of Emperor Augustus (63 BC-
14 AD), who developed such services. The Romans medical services
comprised physicians, surgeons, hygiene officers and bandagers whom
called capsarii, where they had been wearing the same uniforms for the
soldiers, and they trained medically within Legion itself, and because they
were on the front lines their ability to provide accurate first aid had been
effective. Also they were supported by special units of horses, stretcher-
bearers, carriages and wagons to help in transporting wounded soldiers to
field hospital (Eastman, 1992; Gabriel and Metz, 1992).
A major public concern in the late 18th
century directed to the
drowning due to high mortality. So that, a society for protecting peoples’ life
from water accidents started in Amsterdam 1767, and later in 1773, the
physician William Hawes started to publicize the efficiency of artificial
Chapter Two: Review of Literature 11
breathing as a way for resuscitation of drowned people, which in turn, led to
founding society for drowned persons in 1774 named the Royal Humane
Society, which had a major contribution in promoting resuscitation (Collins,
2007; Price, 2014).
Hence, the historical roots of first aid as a profession in its own right
belongs to about 120 years ago or few more. In which, military surgeons and
Royal Humane Society instructions’ contributed in first aid evolution (Pearn,
1994).
Later in early 19th
century Baron Dominique Jean Larrey, the
Napoleon’s famous surgeon created ambulance corps and called flying
ambulance in French, in which aimed to provide first aid during battle
(Efstathis, 1999). After that, Jean Henri Dunant witnessed the consequence
of Solferino battle in 24 June 1859 and his future work led to establishment
of Red Cross, which it is still the largest worldwide provider for first aid
(Pearn, 1994).
Credit goes to the development of first aid to the British Surgeon-
Major Peter Shepherd and before him to the Prussian surgeon Friedrich Von
Esmarch. In 1870, Friedrich Von Esmarch was the first person who
introduced an official organized first aid to the Prussian army and used the
term “erste hilfe” which its translation to English means first aid. Also he
trained the soldiers to provide first aid including bandaging and splinting
skills, for wounded comrades during Franco-Prussian war and designed
Esmarch bandage to show the soldiers the accurate way of first aid (Efstathis,
1999).
Thereafter, Shepherd noticed the worth and importance of Esmarch’s
effort, and his new instructions in bandaging and basic first aid skills. So
that, Shepherd quickly developed and extended first aid skills for medical
division in British army. In 1878, Surgeon-Major Peter Shepherd with help
of Colonel Francis Duncan and doctor Coleman, held the first public first aid
Chapter Two: Review of Literature 12
course in Woolwich, London. Soon later, the St John Ambulance
Association organized similar classes in other British cities. Consequently,
more than one thousand persons had been trained on first aid within a year.
The members of St John Ambulance Association were the first people whom
used the English term first aid (Pearn, 1994; Efstathis, 1999).
It didn’t take so long after the first public first aid classes to test the
readiness of community in applying first aid, where after nine month of
Shepherd training class Woolwich disasters happened. These two tragedies
despite of high rate of deaths, approved the importance of providing first aid
by people at site of incidence as possible before transporting the victims or
before professional medical helps arrive (Efstathis, 1999).
During the 20th
century and later 21th century many scientific
researches had conducted regarding first aid knowledge and practices
(Langley and Silva, 1986; Gagliardi et al., 1994; Conrad and Beattie, 1996;
Altintaş et al., 2005; Başer et al., 2007; Yurumez et al., 2007; Al-Robaiaay,
2013; Al-samghan et al., 2015; Khatatbeh, 2016).
2.2. Section B (Literatures Regarding General Information
About First Aid):
The concept of first aid, since its modern evolution has formulated
many definitions. Despite of maintaining the essence of the first aid
definition but they began to differ in the built-in as needed, and there became
the existence of the first aid in many practical and scientific fields. The field
of first aid is affected by both training and regulatory constraints. Therefore,
the definition of this scope mutable and could be defined regarding to
surrounding circumstances, needs and regulations (Singletary et al., 2015).
First aid entered many disciplines and become more advanced and multi
diverged such as pediatric first aid, mental health first aid, wilderness first
aid, sport first aid, aquatic first aid and so many other disciplines. For
example of various definitions of first aid, 2004 manual of first aid definition
Chapter Two: Review of Literature 13
was “first aid is the temporary and immediate care given to the person who
is injured or suddenly become ill” (Gupta, 2004). Soon later, 2005 California
code of regulation defined first aid as “first aid is any one-time treatment and
any follow up visit for the purpose of observation of minor scratches, cuts,
burns, splinter etc., which do not ordinarily require medical care.” (Kirby
and Mather, 2005).
The 2010 Guidelines for first aid, stated by American heart association
and American red cross defined first aid as “the assessment and interventions
that can be performed by a bystander or by the victim (self-care) with
minimal or no medical tools.” (Markenson et al., 2010). Later American
Academy of Pediatrics set pediatric first aid definition according to their
discipline, it was defined as the initial medical care that you give to a child
who is injured or suddenly become sick (American Academy of Pediatrics,
2012). After that, American heart association and American red cross
updated their definition in 2015 and referred to first aid as assisting activities
and immediate care obtained for severing illness or sudden injury with
purpose of life’s preservation, suffering alleviation, additional illness or
injury deterrence and recovery promotion (Singletary et al., 2015).
First aid is complex and situation specific, so that more informed and
better trained, first aiders are more eligible to deal with unexpected illness
or sudden injury (Saubers and Iannelli, 2008). Thus first aid must be
medically sound and based on scientific knowledge, and in absence of such
knowledge, the expert must be consulted. First aid can be obtained by
everybody and comprises self-care, so that first aider can be any person exist
in the scene of emergency and provides such care like parents, teachers,
policeman, fireman, first responder, professional medic, etc. (Piazza, 2014;
Singletary et al., 2015).
There are three main objectives for first aid, firstly to preserve life, not
merely victim’s life, but first aider’s life as well. Because if first aider put
Chapter Two: Review of Literature 14
his/her life in danger might ends up struggling for his own life instead of the
victim’s. Secondly to avoid worsening of condition. The third aim of first
aid is to encourage recovery, which means first aider actions should assist
injured person toward improvement, certainly after preventing situation
from getting worse (Barraclough, 2015).
First aider qualifications include the ability to: first aid needs
estimation, assessment and prioritization; using suitable knowledge, skills
and behaviors to obtain appropriate care; and finally recognition for any
limitation and looking for further care when it’s needed (Singletary et al.,
2015).
The way that the first aider must act during an emergency is an
important issue, these actions according to their priorities are: foremost the
first aider must make sure that the scene of accident is safe and there are no
instant hazards such as fallen electricity lines or hazardous materials; second
action is to check for any life threatening conditions (e.g. severe bleeding,
breathing difficulties or loss of consciousness); then the first aider should
call for emergency medical services and perform Cardio Pulmonary
Resuscitation (CPR) if needed and ask for near help if not trained for CPR;
after that the first aider must stop any bleeding and check for any head, neck
or spinal injury and must not transfer the victim except if it is required (Jones,
2012). The next step in first aider action is to look for any indicators for
special health problems such as diabetes mellitus or asthma, through any
medications or drug prescriptions, also the first aider must stay calm and
quiet during emergency and act quickly to save victim’s life until medical
helps arrive. Avoiding direct contact with blood and other bodily fluids if
not wearing disposable gloves is an essential matter. Finally the first aider
should use proper hand washing technique before and after first aid
administration (Jones, 2012).
Chapter Two: Review of Literature 15
First aid priority always given to life threatening cases. The (A and B)
priority of treatment for any case is to make sure that the airways are open
and the victim is breathing normally, and this is called the primary survey,
the moment that first aider became sure that the victim is breathing normally
the (BBB) is the next priority and it’s given to deal with any bleeding and
after that to deal with bone injuries, so that this called secondary survey as
in (figure 2.1) (Barraclough, 2015).
Figure 2.1. Priority of Treatment. Adopted from First aid made easy manual, by (Barraclough,
2015)
Baser et al., 2007 conducted scientific research to evaluate and
determine Turkish primary school teachers’ knowledge and attitude
concerning first aid. The study sample included three hundred twelve
primary school teachers asked on first aid for hemorrhage, epistaxis,
wounds, object aspiration and insects’ stings. The study result indicated that
the progress of primary school teachers’ age was accompanied with more
unlikely first aid practices and attitudes. Finally, study pointed that the
knowledge and attitude of primary school teachers toward first aid was
Chapter Two: Review of Literature 16
insufficient and recommended for first aid and pediatric basic life support
training (Başer et al., 2007).
During the same year a study in Poland done by Wisniewski &
Majewski 2007 to assess knowledge and attitude about first aid among
selected high school teachers in the western Pomerania region. Sample of
one hundred school teachers encompassed in this survey from two high
schools of two polish cities. The study tool used in this work was a consistent
questionnaire used formerly to determine problems of providing first aid
among Polish society. The study result showed that despite the fact that the
majority of targeted teachers previously had first aid courses, the level of
their knowledge required to provide first aid was insufficient. For example,
the result indicated that 50% of teachers had theoretical knowledge about
rules of providing first aid but only one third of the respondents were able to
put these theoretical rules into practice in reality. Also the majority of
teachers demonstrated negative attitude toward providing first aid in
emergency cases. So that, the study concluded that the training for
administering first aid is mandatory for teachers as well as pupils and should
be done by medical professional staff, and the study did not omit to mention
the importance of changing negative attitude of teachers during first aid
session by focusing on ethical value of human assistance (Wiśniewski and
Majewski, 2007).
Few years later, Ali et al., in 2010 performed an educational training
program about first aid for recently graduated nursery school teachers and
aimed to develop, implement and evaluate such program about first aid for
emergencies happening in preschools. The interventional program included
60 female participants of recently graduates of specific education college,
university of Zagazig. The data collection of study divided into three parts,
in the first part a questionnaire used to assess teachers’ knowledge regarding
first aid, and during second part an educational program implemented on
twenty sessions (30 - 45) minute per session, and also participant teachers
Chapter Two: Review of Literature 17
were distributed to smaller groups during practical sessions and finally the
third part was an evaluation of program by analyzing the pre and post test
results of the respondents. Besides an observational check-list used to assess
participants first-aid practices regarding wounds, seizure, fractures,
epistaxis, burns and choking. The result confirmed that a significant
improvement of knowledge and practice from (0 – 10%) at pre-test to (80-
95%) in post-test result scores, which indicated that the program was
successful, hence, the study recommended to add first aid practical courses
for undergraduate curriculum and periodic training courses for graduated
nursery teachers (Ali et al., 2010).
During the next year Bildik et al., in 2011 adopted study purposed to
define the education faculty students’ level of first aid knowledge and
evaluate training administered to them. The study sample encompassed
eighty-eight students from university of Gazi, faculty of education in capital
Ankara. Almost 20 hours of training for first aid provided completed in 3
months, and pre-test/post-test questionnaire plus final exam performed for
participants. Results of the study noticed significant improvement in
knowledge and skills after training (Bildik et al., 2011).
Hirca 2012 reviewed Turkish literatures regarding first aid, the
research entitled “does teachers’ knowledge meets first aid needs of Turkish
schools?” and obviously aimed to assess if teachers of Turkish schools
having adequate first aid knowledge throughout reviewing preceding articles
done in this field in Turkey. The study outcome revealed that the knowledge
of Turkish school teachers on first aid was ranging from moderate to
unsatisfactory. Most of teachers formerly did not get correct information
regarding first aid and even if they had previous training on first aid, it was
limited on theoretical sides not practical sides in such sessions. Finally, the
study recommended for applying more researches and studies to investigate
knowledge of teachers in first aid skills (Hırça, 2012).
Chapter Two: Review of Literature 18
Later, in 2013 Al-Robaiaay conducted study on primary school
teachers’ knowledge about first aid in Baghdad, Al-Rusafa. The objective of
the study included estimation of knowledge of primary school teachers about
first aid for situations like fractures and external bleeding and determination
effect of years spent on teaching on knowledge levels of teachers and
whether there was needs for first aid training or not. A cross-sectional study
carried out in several areas in Baghdad, Al-Rusafa over five months and
included one hundred primary school teachers (26% of them were science
teachers and 22% of them were art and sport teachers). The result showed
that only 4% of participants had good knowledge, while 19% of them had
fair knowledge but the larger proportion of them (77%) had poor knowledge
about first aid. Besides to inadequate knowledge of teachers that concluded
by the study, also the study noticed that both years spent in teaching and
material taught by teachers had no significant effect on teachers’ knowledge.
Al-Robaiaay recommended for regular first aid training and also adding first
aid education to syllabus of institutes that prepares future teachers (Al-
Robaiaay, 2013).
Furthermore, in 2013 Kumar et al., carried out a study aimed at
assessing practices and perceptions of school teachers toward first aid, and
to find rapport between sociodemographic characteristic and first aid
practices, and also to discover any factors that may influence teachers’
perceptions and practices regarding first aid. A cross-sectional study design
applied for nine months by using self-administered questionnaire which was
tested formerly, and included forty school that selected randomly in city of
Mysore. From 262 school teachers involved in the study 57.3% were from
urban areas while 42.7% from rural ones, additionally, 49.6% of teachers’
age was above 40 years old. Despite of study results that exposed already
97.3% of selected teachers were heard the term first aid previously, just
78.8% of them comprehended that wounds needs first aid and only 30.2% of
them were mindful that fainting needs first aid. So that, the total deduction
Chapter Two: Review of Literature 19
referred that teachers’ perceptions and practices regarding first aid is poor
and disappointing (Kumar et al., 2013).
Devashish et al., in 2013 performed a research to evaluate teachers’
knowledge and practices about first aid, their readiness and if they need first
aid training in the city of Vadodara. The study done through cross-sectional
design and included 236 school, which two teachers selected from each
school (one teacher of physical education and the second teacher from other
subjects) and the total number of respondents were 472 teachers (394 males
and 78 females), and the study lasted from January 2010 to December 2010.
The result of the study showed that just 2.96% of teachers were previously
trained on first aid, 14.83% of teachers answered correctly 70% of the
questionnaire. Also the authors noticed a significant association between
first aid training and better knowledge and also noteworthy association
between knowledge score and age, gender, teaching experience and school
level (primary, secondary and higher secondary) had been recognized.
Generally, paucity in knowledge of teachers detected and based on results of
study, the researchers concluded and recommended that first aid training is
important and must be regular and updated as well as it must continue
throughout teachers’ professional career (Devashish et al., 2013).
Sonmez et al., in 2014 conducted a study that aimed to evaluate
preschool teachers’ knowledge regarding first aid practices in city of Isparta,
Turkey and to identify factors that may affect such levels of knowledge.
Total 110 of preschool teachers included in this cross-sectional study by
using a questionnaire consisted of 20 points scale. Study result pointed that
washing a wound after a dog bite by soap and water and immobilization of
fallen child from high altitude were the issues which had lowest knowledge
by participants, and their scores were 16.4% and 20.9%, respectively.
Additionally, the findings of the study revealed that the age, employment
years, previous first aid training and previous experience with situation that
Chapter Two: Review of Literature 20
needs first aid had no significant effect on teachers’ levels of knowledge.
Likewise, the study detected that participants had poor knowledge and since
first aid training did not show noteworthy differences on their knowledge,
the researchers inference was that the quality of training need to be received
is a fundamental matter (Sönmez et al., 2014).
Another study done by Ammirati et al., in 2014 aimed at assessing the
knowledge assimilated by children below 6 years of age who were trained
by their own teachers and after that comparing the results with another group
of untrained children. The study included training teachers on first aid by
professional medical emergency staff then 315 pupils selected randomly and
divided to 18 classes (nine of them for trained pupils and nine of classes for
untrained ones). The majority of trained pupils provided the expected
answers, besides the trained group revealed paramount ability to describe
emergency situations and had better alert for emergency conditions that
needs first aid. The study leveled that those small children were able to
assimilate first aid skills taught by teachers and also not forgot to mention
that public health goal of trained teachers as well as pupils regarding first aid
cannot be reached without providing qualitative education and training to
teachers to make them able to transfer such skills and knowledge to others
(Ammirati et al., 2014).
Shobha Masih et al., in 2014 conducted a quasi-experimental study
with one group in Dehradun district of Uttarakhand. The study aimed at
evaluating the efficiency of educational program on information of teachers
regarding first aid for minor injuries in school children. 50 primary school
teachers were selected by convenience sampling, and 94% of selected
teachers were female, the result showed that 72% of them experienced
previous injuries in school children and 86% of them had no previous
training about first aid, but instead of that 74% of them had appropriate
knowledge about first aid from other sources like: reading, friends, relatives
Chapter Two: Review of Literature 21
and health professionals personnel. The study concluded that the applied
program was effective and revealed the further need for such programs to
improve the total health standards for school children (Masih et al., 2014).
A year later, Al-Samghan et al., in 2015 applied a study to explore the
knowledge of primary school teachers regarding first aid. The study was
carried out using descriptive/cross-sectional design and included 187
teachers of governmental primary schools of Abha city in Saudi Arabia. A
self-administered questionnaire used among participants in boys’ schools
only. The result showed that teachers’ mean of age was 41.5+7.4 years and
ranged from 25 to 58 years. The result cleared that 28.3% of teachers
attended courses on first aid while 62.3% of those had first aid courses
reported that these courses included practical training. Moreover, only 31%
of them had acceptable knowledge regarding first aid for poisoning, while
52.4% of them had satisfactory scores regarding first aid for bleeding.
Overall conclusion of study revealed unsatisfactory knowledge among
respondents. So that, the researchers recommended to introduce first aid
education and training in curriculum of schools, institutions and colleges, as
well as recommended to apply such studies in girls’ primary schools and also
secondary schools and declared the obvious need for more researches in this
field for future (Al-samghan et al., 2015).
Abdella et al., in 2015 performed an interventional program regarding
first aid for kindergarten teachers which aimed at evaluating effectiveness of
applied program on teachers’ knowledge and practice regarding first aid.
Fifty teachers of governmental kindergarten included by using convenience
sampling method. In general, and brief term, the result of the study detected
significant improvement for both knowledge and practices of involved
teachers. The study concluded that the good improvement in teachers scores
synthesized by a well-designed program. Moreover, adding first aid learning
and training to core curriculum of faculties that prepare future teachers and
initiating periodic sessions for first aid to refresh and improve teachers’
Chapter Two: Review of Literature 22
information and skills, were recommended by researchers (Abdella et al.,
2015).
2.3. Section C (Literatures Regarding Wounds and Bleeding):
2.3.1. Wounds and Bleeding:
Human history is full of a lot of evidence on the wound care across
civilizations. From clay tablet, which is one of the ancient medical scripts
that dates back to 2200 BC which described the three assisting wounds
healing steps, and passing through the ancient Egyptian papyruses dating
back to 1400 BC, that documented open wounds’ treatment by putting honey
and grease into open wounds to improve healing, and even arriving to
Hippocrates 400 BC the Greek physician who used piece of tin pipe to inject
fluids and to suck pus out of wounds, and so many other examples reaching
to our recent days contributed in wound caring and healing, as well as
evolution of wound infection prevention (Broughton et al., 2006; Shah,
2011).
The breakdown in the skin and underlying tissues causing wounds, as
well, Physical injury or mechanical forces (for instance surgical incisions)
may result in wounds (Taylor et al., 2011).
According to Fundamentals of Nursing Standards and Practice 2011
wounds can be classified according to various terms, but usually described
based on the causes. So that, classification based on causes of wounds are:
1- Intentional wounds: occurs due to treatment and usually done under sterile
circumstances e.g. surgical incisions.
2- Unintentional wounds: mostly, follows trauma or accident. These wounds
are unanticipated and occurs in unsterile situation, which makes risk for
infection higher (DeLaune and Ladner, 2011; Sussman and Bates-Jensen,
2012; Berman et al., 2016).
Furthermore, another classification set depending on skin integrity,
and categorized wounds into:
Chapter Two: Review of Literature 23
1- Open wounds: occurs by break of the skin or surgical incision.
2- Closed wounds: may be caused by external blow or crushing and
includes internal hemorrhage (Nugent and Vitale, 2014; Burton and Ludwig,
2015)
Proper wound care is necessary to promote healing that results in an
intact skin layer. Intact skin is the first line of defense of the body against
invasion by infectious microorganisms. The skin defends the body in other
ways by serving as a sensory organ for pain, touch, and temperature (Bryant
and Nix, 2015).
First aid procedures for open wounds done through the following
steps:
First of all, in case of no severe bleeding the wound must cleaned by
rinsing it gently under running water with soap to minimize risk of infection
and clean the wound then using disinfectants or sanitizers (American
Academy of Pediatrics, 2012).
Then placing the injured child in proper position, after that, looking at
the wound for any foreign bodies. Subsequently, raising the wound site
above heart’s level, later, performing direct pressure with disinfected or
clean dressing that is enough for covering the wound (Barraclough, 2015).
Meticulously, bleeding caused by injury wounds may cause serious
threat to the life of casualty, particularly if the amount of blood loss was
more than one liter so that techniques used to stop bleeding are an important
matter and includes: direct pressure, indirect compression points, and
tourniquet (constricting stretchable band that tied strongly above the wound)
used to evade massive blood loss (Usman and Davidson, 2014).
For direct pressure keeping an eye on the following steps is necessary:
1- Carefully, taking out any foreign body sticking into the wound.
2- Using a sterile or clean bandage and wrapping it gently around the
wound and applying direct pressure till the bleeding stops.
Chapter Two: Review of Literature 24
3- If the bandage or dressing used very immersed or soaked with blood
without removing it, putting more dressing around bleeding site as an
alternative.
4- If the bleeding is in arms or legs, raising that part above heart’s
level, in order to decreasing blood oozing thru the wound.
Pressure points are used in case the direct pressure was ineffective,
and the bleeding persists. Thus, the pressure points for body parts in brief
terms are as next:
- The pressure point for arm bleeding is superior part of arm, below the
armpit (axilla).
- Forearm pressure point is the inner (interior) part of arm, just under the
elbow.
- The wrist is the site of pressure point application for hand bleeding.
- The pressure point for skull bleeding is the temple (tempora) an area
located behind the eyes.
- For neck bleeding the pressure applied to carotid vessels which are located
a little away from mid-line of neck (Rhoads and Meeker, 2008; Usman and
Davidson, 2014).
2.3.2. Epistaxis:
The history of providing first aid for epistaxis, backs in date to 5th
century BC, which Hippocrates mentioned how to stop nose bleeding, in a
time noticed development of scientific medicine in ancient Greek society
(Pikoulis et al., 2004; Aydin et al., 2009; Al-azzaawi et al., 2014).
Epistaxis refers to the nose bleeding or hemorrhage from the nose and
commonly originates in the anterior portion of the nasal cavity (Nettina,
2010). Nose-bleeding is common significant problem which may cause
extreme anxiety to the patients and their families; in addition, up to 60% of
general population affected by epistaxis for one time at least, which usually
can be stopped with simple home remedies or stop on its own without any
medical management, but occasionally nose bleeding may be huge and
Chapter Two: Review of Literature 25
deadly (Chaiyasate et al., 2005; Mann et al., 2005; Hussain et al., 2006;
Kucik and Clenney, 2011; Mcgarry, 2013). Likewise, up to 60% of children
suffers from epistaxis for one time at least by age of ten (Davies et al., 2014).
Recurrent nose-bleeding due to unknown causes occurs in about 9%
of children between age 1 and age 16, and generally is simple and self-
limiting but only severe cases referred for professional medical treatment,
even though there is no consensus on effective methods to treat epistaxis,
besides, epistaxis treatment has undergone important modifications in latest
years (Douglas and Wormald, 2007; Qureishi and Burton, 2012; Mcgarry,
2013).
Epistaxis or nose bleeding resulted from many causes such as trauma,
structural alteration or pathological origins (Ward, 2014). According to
Lippincott Manual of Nursing Practice, 2010 these causes can be categorized
to:
1- Local causes such as:
a. Dryness leading to crust formation and bleeding occurs with
removal of crusts by nose picking, rubbing, or blowing.
b. Trauma e.g. direct blows.
2- Systemic (pathological) causes which are less common, for
example hypertension, arteriosclerosis, renal disease and (bleeding disorders
which are most common among systemic causes) (Nettina, 2010).
First aid management for epistaxis depends on severity and cause
of bleeding but usually includes:
1- Placing the child in an upright position then leaning him/her
forward to reduce venous pressure, and asking the child to breathe gently
through the mouth to avoid swallowing of blood.
2- compressing the soft part of nostril using index finger and thumb
for 5 to 10 minutes to keep pressure on the nasal septum and some first aid
guidelines recommends that before applying the pressure to nostril, to ask
Chapter Two: Review of Literature 26
the child to blows his/her nose gently to reduce the amount of dried blood
before bleeding stops. These two steps presented visually in (figure 2.2).
3- As advanced procedure if the bleeding did not stop a cotton pledget
soaked with a vaso-constricting agent then inserted into each nostril, and
pressure is applied if bleeding is not controlled by compression alone, after
5 to 10 minutes, the cotton is removed, and the site of bleeding is recognized.
Figure 2.2. First Aid for Nosebleeds. Adopted from The Everything First Aid Book
by (Saubers, 2008).
4- In case of recurrent epistaxis further medical diagnostic measures
and cares needed by referring the child to medical facilities (Nettina, 2010;
American Academy of Pediatrics, 2012; Mulla et al., 2012).
A postal survey done in 2010 among teachers of local South Wales
schools to explore epistaxis rate of recurrence and management in school
setting. Total 112 questionnaires were returned from total 157 questionnaires
distributed to 116 primary school and 41 secondary school. Therefore, 32
secondary school teacher and 80 elementary school teacher responded to
study tool. The results showed that only 25% of secondary teachers and
37.5% of primary teachers were aware on rules of nose bleeding
management. The study concluded that notwithstanding of frequently
Chapter Two: Review of Literature 27
occurrence of epistaxis in schools, the teachers used incorrect methods to
stop epistaxis, in addition to the fact that most epistasis cases stops
spontaneously (Robertson, King and Tomkinson, 2010).
In 2015 another study conducted by Banafi et al., on prevention of
accidents and first aid knowledge for parents of preschools’ students, and
included six Hungarian kindergartens. Only 234 self-administered
questionnaires obtained from all 307 that were distributed. The study result
showed that 74.3% of the respondents faced at least one accident previously,
while 74.4% of them had previous training on first aid. As well as, about
(3/4) of them (73.5%) answered correctly on epistaxis question, while 18.8%
of them reported that the child must lean his/her head backward which makes
higher risk for blood aspiration. The highest level of knowledge toward
epistaxis and choking matched previous study in Taiwan. Finally, the total
knowledge of first aid detected unsatisfactory despite of high scores in
choking and epistaxis management. Thus, the researchers recommended to
apply a wider survey to detect the population knowledge on first aid and to
organize first aid sessions to increase the knowledge about first aid (Bánfai
et al., 2015).
2.4. Section D (Literatures Regarding Bone Injuries and
Fractures):
Human attempts for early care and treatment of fractures and other
bone injuries were noticed through the history. Edwin Smith Papyrus (1600
BC) described bandaging of humeral fracture preceded by reduction using
traction and also mentioned shoulder dislocation management by reduction.
Likewise, many other ancient Egyptian manuscripts referred to approaches
for orthopedic surgery established by them. Later, the scripts noted by Greek
physician Hippocrates described fracture reduction in detail and noted the
bandaging and splinting of fractures. The Roman Celsus (25 BC – 50 AD)
described many issues regarding skull fractures and depressed fractures,
Chapter Two: Review of Literature 28
some of these issues were founded accurately in comparing with our recent
medicine. And so that the mankind history until our days, witnessed many
remedies and interventions regarding fractures’ first aid and treatment.
(Brorson, 2009; Blomstedt, 2014; Ganz and Arndt, 2014).
Globally, the foremost reason of mortality, disability and morbidity
among children is injury. As well as, many studies estimated that these
common childhood injuries affect about 25% of children annually.
According to WHO fractures are the most common types of childhood
accidental injuries that affect kids below 15 years of age and necessitates
hospitalization in developing countries. In addition, fractures consist about
10 to 25% of all juvenile injuries. Besides, about 3-11% of school children
are injured in sport activities during school time (Rennie et al., 2007;
Shanmugam and Maffulli, 2008; Khadilkar et al., 2015).
A fracture is defined as “an incomplete or complete disruption in the
continuity of bone structure” and knew according to its type and extent, and
usually fracture occurs when the bone is exposed to a great stress more than
its ability to tolerate (Smeltzer et al., 2010); Or in another word, a fracture
defined as a loss or shatter of the bone (Judge, 2005; McRae and Esser,
2008; Walker, 2013).
Fractures are classified into several types according to many criteria
such as mechanism, displacement, pattern, pathology, fragments and
location; but generally classified into open and closed fractures (Whiteing,
2008).
Open fractures (complex or compound) are defined as fractures in
which skin or mucous membrane wound extended to the fractured bone or
the fractured bone breakout through the skin, while closed fractures (simple)
are defined as fractures in which no skin or tissue disruption occurs by
fractured bone (Whiteing, 2008; Dandy and Edwards, 2009; Smeltzer et al.,
2010; Wright, 2014)
Chapter Two: Review of Literature 29
Common types of open and close fractures (Transverse, Oblique,
Spiral, Comminuted, Avulsion, Impacted, Fissure and Greenstick) are
showed in figure (2.3).
Figure 2.3 Types of fractures. Adopted from Orthopedic and Trauma Nursing by (Clarke &
Santy-Tomlinson 2014).
First aid intervention for musculoskeletal injuries such as fractures,
sprains or even strains generally includes the principle of RICE, which
means the following:
- “R” refers to REST: and means the injury must be placed in rest
(comfort) situation and any effort should be banned, e.g. don’t allow
the child play or move by his/her own on injured area or even the
first aider must be cautious to keep his weight away from injury site
and not move the bone to prevent fragmentation of bone (Dvorchak,
2010; American Academy of Pediatrics, 2012; Barraclough, 2015).
- “I” refers to ICE: and means that an ice or cold pack should be placed
on site of injury to help in vasoconstriction of blood vessels and thus
will help in reducing swelling; this must be applied as soon as
possible for 10 minutes and should be repeated every 2 hours for 24
hours or 48 hours as maximum (Saubers and Iannelli, 2008;
Barraclough, 2015).
- “C” refers to COMPRESSION: and means necessity of using an
elastic or firm bandage to injured musculoskeletal area (Piazza,
2014; Barraclough, 2015).
Chapter Two: Review of Literature 30
- “E” refers to ELEVATION: and means the affected area must be
elevated to reduce swelling specially in joint injury (Barraclough,
2015).
The first aider must keep in his/her mind some important notes such as:
never attempt to straighten a knee joint by force and never try to align the
ends of an open fracture, and also don’t give the casualty any fluids or foods,
because a surgery may be needed. Furthermore, the affected area must not
be rubbed, and the joint below and above fracture must be immobilized
(Meredith, 2006; Dvorchak, 2010).
The immobilization done by using splints or slings or both as needed
and according to fracture’s type or site Figure (2.4), the splints used to
immobilize the joint below an above fracture and it should be firm, lengthy
and wide enough for fixing the joint below and above the fracture and
prevent any movement immediately, and it may be an umbrella, piece of
wood or even a rifle, while the sling made of triangular or roller bandage and
used to immobilize some parts of body such as jaw, collar bones or limbs
and the slings may be spontaneously selected from surroundings area of
injury, it may be a belt, shoe lace, piece of cloth or even neck ties (Karesh,
2012; Gloster and Johnson, 2016).
The fracture’s intervention is differing in detail according to location
and type of fracture, thus first aid for neck, head, legs, arms, fingers, pelvis,
ribs, spinal cord and other types of fractures are the same in general principle,
but may contrast in detail and type of interventions needed. Therefore,
dealing with different fractures in depth, needs first aider provided with
proper training and knowledge on first aid.
Chapter Two: Review of Literature 31
Figure 2.4 A. Fixing with splint only B. Fixing with both splint and sling. Adopted
from First Aid for Nurses by (Karesh, 2012).
Another common musculoskeletal injury among school aged children
are sprains, which are relates directly to early engagement in sport activities
since primary stages of their life, and increased principally during last years
as a way for improving body fitness , which makes risk for injury more
factual (Caine et al., 2008; Gottschalk and Andrish, 2011; Doherty et al.,
2014; Dorje et al., 2014). Globally, almost one ankle sprain occurs in
everyday per ten thousand persons (Waterman et al., 2010).
Sprains are defined as injuries to ligament, which are band of tissues
that hold bones in position and connect them to other bones or to the joints.
Common signs and symptoms of sprain are: pain and tenderness, fast
swelling of area, discoloration of skin and bruising in area. Concisely,
emergency first aid for sprains includes immobilization, elevation,
application of cool pack and referring to a health facility for further
professional medical care (Jones, 2012; Flegel, 2014; Stephens, 2016).
Sundblad et al., in 2005 conducted a study about injuries of school
children during physical activities. The outcome of study showed that most
common kind of injuries among study population were strains and sprains
(49% of all injuries), while the wounds made only 14%. However, the rate
incidence for fractures were 5%, for dislocations 4% and for concussions
Chapter Two: Review of Literature 32
5%. As well, 33% of injured children were attended by parents or other
grownup household member, while the class teachers and sport trainers
cared for 26% of all incidence. Besides, the physicians and school nurses
cared 17% and 24% of all injuries, respectively. This study revealed the
importance of providing first aid training and increasing related knowledge
for class teachers, educators and sport coaches, because the school teachers
are the first persons which confronting child emergencies at school
(Sundblad et al., 2005).
Albrecht & Strand in 2010 applied a survey study on sport coaches’
knowledge and qualification concerning first aid. From total 594 of school
coaches participated the study only 154 completed the survey questionnaire
that was consisted from four sections about first aid for injuries and sudden
illnesses, as well as questions about CPR/AED. So that, the results revealed
higher knowledge and confidence when confronting an emergency for
teachers with first aid certification in comparing to those without
certification. Thus, the researchers underlined the importance of giving
official and high quality training for school sport teachers (Albrecht and
Strand, 2010).
2.5. Section E (Literatures Regarding Other Medical
Emergencies and Illnesses):
2.5.1. Asthma:
The historical chronicles denoted that the ancient Chinese and
Egyptians were the first nations who treated asthma. But the origins of the
word asthma back in date into Greek term “aazein” which its literal
translation into English means “to pant or exhale with open mouth”.(Gordon,
2008; Singh and Singh, 2014; Bhattacharjee et al., 2015; Tanaka, 2015).
Asthma is considered as very common respiratory disorders, and
higher level for asthma incidence recorded throughout the last decades.
Likewise, asthma is a world challenging health problem, which according to
Chapter Two: Review of Literature 33
WHO it affects around 235 million persons around the globe and annually
kills more than 180.000 person, and as well as global childhood mortality
due to asthma range between 0.0 to 0.7 per 100.000 every year. Furthermore,
the children are the most age group influenced by asthma which is most
common chronic childhood illness especially between ages of 5 to 14 years
(Subbarao et al., 2009; WHO, 2013; Asher and Pearce, 2014).
Asthma is defined as chronic airway inflammation or increased airway
responsiveness that leads to dyspnea, wheezing and coughing or even
variable airway obstruction (Innes and Maxwell, 2016).
Sign and symptom of asthma attack generally are: productive cough,
dyspnea, using accessory respiration muscles, tachycardia, tachypnea and
noticeable expiratory wheezing (Japp and Robertson, 2013; Linton, 2016)
The factors that increase risk of asthma attack and considered as
triggers (acute asthma exacerbations) are:
1- air pollution. 2- allergens such as dust. 3- exercise (exercise induced
asthma). 4- hormones (in females during menstruation). 5- occupational.
6- psychological.(Greener, 2015).
Asthma first aid management includes following actions:
1- First of anything giving the medication of asthma that the child brought
with him.
2- Remain providing inhaler, one puff per minute.
3- Putting the child in a comfortable position which makes breathing easier
to him (sit him/her upright or lean forward).
4- Loosen the child’s clothes to ease the breathing.
5- helping the child to breath slowly (inhale/exhale).(McMurray, 2011).
A pilot study conducted in 2012 in a rural school in Illinois, USA by
Lucas et al. about primary school teachers’ knowledge concerning asthma
care in children. The questionnaire used contained common information on
asthma and its related management. The result revealed insufficient
knowledge among the respondents, besides, the result noticed that teachers
Chapter Two: Review of Literature 34
were not ready to deliver asthma care. Thus, the researchers recommended
to educate teachers on health issues and any cares needed, to insure
protection of kids during class period (Lucas et al., 2012).
A prospective, cross-sectional research conducted in Quetta, Pakistan
in 2015 by Aqeel et al., in order to assess teachers’ knowledge and awareness
toward asthma and factors that may increase the risk for asthma attacks. The
study concluded that a training programs needed to improve teachers’
knowledge about asthma symptoms and proper care needed in asthma
emergency situations. Thus, researches recommended to organize such
sessions and programs in Quetta, Pakistan to ensure pupils health safety
during school time (Aqeel et al., 2015).
2.5.2. Epilepsy:
The earliest description of epilepsy backs in date to Akkadian
civilization in ancient Mesopotamia around 2000 BC. In nutshell, the
contribution of ancient Iraqi civilization about epilepsy description,
diagnosis and treatment was very clear, in spite of it connectedness to many
myths. The real origin of word epilepsy that is used in our time relates to
Greek verb (epilambanein), which means “possess, distress or to take hold
of”. These studies continued since antiquity and until it developed in our
recent times due to huge progression and discoveries in medicine (Devinsky
and Lai, 2008; Magiorkinis et al., 2010; Wang et al., 2011; Magiorkinis et
al., 2014).
Epilepsy is one of the oldest and common non-communicable disease,
affecting nearly 50 million persons around the globe, and it’s expected to
increase every year. The global childhood incidence of active epilepsy
estimated around 10.5 million children, which represents 25% of total
epilepsy population around the globe. What makes epilepsy an important
issue, is that the most age group vulnerable to injury due to epilepsy are
children; and as it known negative effect of epilepsy on personal life it’s also
severely influences the social life of epileptic children and thus their quality
Chapter Two: Review of Literature 35
of life in home, schools, community, etc.(Calisir et al., 2006; Guerrini, 2006;
De-Boer et al., 2008; Ngugi et al., 2010; Camfield and Camfield, 2015;
Davidson et al., 2016).
Epilepsy classified into generalized and partial. Also, the partial
epilepsy classified into simple and complex, while generalized epilepsy
categorized into tonic-clonic, absence, myoclonic jerks, tonic and atonic
seizures (Glasper et al., 2015; Harrisson, 2016).
Clinical features of seizures influenced by: brain parts affected (one
part or more), pattern of spread of through the brain, age and epilepsy
etiology (Glasper et al., 2015).
Management of seizure differs according to types, but generally the
first aid actions for epilepsy are as next:
1- Protecting epileptic child from injury, by removing any close harmful
stuffs especially in generalized seizures.
2- Supporting the victim’s head, by placing billow, towel, blanket, soft pad
or folded clothes under the head.
3- Placing piece of wood or anything between the teeth to prevent him/her
from biting the tongue.
4- loosen the tied clothes to ease the breathing.
5- Turning the victim on his/her side if there was fluid getting out from the
mouth (milk, blood or saliva) in order to drain the fluid out.
6- Observing the child until the seizure ends then putting the child in
recovery position for a while until breath normally and be more conscious.
7- If the child became blue CPR must be provided.
8- The first aider must never attempt to hold or replace the epileptic victim
(American National Red Cross, 2007; O’Hara, 2007; AAP, 2012).
In 2013 a community based research conducted on knowledge,
attitude and perception of secondary school teachers in Osogbo, Nigeria. The
study results showed there was a shortage in their knowledge about first aid
actions. Generally, a positive attitude noticed among most of teachers. The
Chapter Two: Review of Literature 36
study recommended for educational courses on epilepsy and other illnesses
in classroom and also on emergency measures needed for such conditions
(Mustapha et al., 2013).
A planned teaching program aboutknowledge and attitude on epilepsy
and its related first aid actions among primary school teachers in Nagpur city
in India and done in 2016. The result showed that there was no significant
relation between first aid management and knowledge and attitude toward
epilepsy, while a significant association founded for age, gender and
teaching experience with both teachers first aid management of epilepsy and
teachers knowledge and attitude toward epilepsy. The conclusion of
researcher based on the results was that the program was successful (Wagh,
2016).
2.5.3. Diabetes Mellitus:
The physicians in ancient Egypt 3500-2000 BC identified the
symptoms of diabetes mellitus (D.M). However, the origins of (Diabetes
Mellitus) is ancient Greece, which the word diabetes means siphon (running
through) and the word mellitus means sugarcoated or sweet. Nutshell, the all
ancient Egypt, Chinese, Greece, Rome, and Indian considered diabetes as a
significant morbidity. As well, the famous Muslim physician Avicenna was
the first one who confirmed the sweet characteristic of diabetic urine (King
and Rubin, 2003; Eknoyan, 2006; Dupras et al., 2010; Zhang et al., 2010;
Laios et al., 2012).
Diabetes mellitus had become a worldwide chronic epidemic in spite
the fact that it is not a communicable disease, but due to high incidence and
prevalence rates. WHO estimation for D.M cases in 2000 was 154 million
persons and founded to be 246 million in 2006, furthermore, by 2025
prospected to be 380 million persons. In middle-east and north African
district, the disease estimated to be almost 9.2% of populations (34 million),
and 17 million of them non diagnosed persons, furthermore, in middle-east
only approximately 60.000 cases younger than fifteen years old founded to
Chapter Two: Review of Literature 37
have diabetes type1 every year. Moreover, in 2013 the mortality of D.M
estimated to be about 4% of all mortality reasons, and it consist the fifth
leading cause of death in Arab world countries and other Asian states like
Korea (Levitt, 2008; Kim, 2011; Majeed et al., 2014; Abuyassin and Laher,
2016; Zayed, 2016).
Diabetes mellitus is a disorder resulted from lack or absence of insulin
production by pancreas or existence of factors opposing the insulin works
(Watkins, 2003; Rosdahl and Kowalski, 2012).
Diabetes mellitus is classified into: insulin dependent (type 1 DM)
which usually affects the children, non-insulin dependent (type 2 DM)
usually affects the adults, gestational diabetes mellitus(which occurs during
pregnancy) and other types like diabetes insipidus, prediabetes (LeMone et
al., 2011; Rosdahl and Kowalski, 2012).
All types of diabetes of mellitus are causing hyperglycemia
(increasing blood glucose levels), thus, the major symptoms of
hyperglycemia are: polyuria, polydipsia (thirst and dry mouth), nocturia
(frequent nightly urination), fatigue, lethargy, muddling of vision,
polyphagia (especially for sweets) and sometimes headache, nausea and
irritability (Pearson and McCrimmon, 2014).
Besides the hyperglycemia that caused by diabetes and needs
management, occasionally hypoglycemia (decreasing blood sugar levels)
occurs which is resulted due to many causes such as excessive diabetes drug
dose, or excessive exercise or during night sleep and considered as life
threatening condition even more than hyperglycemia, and most usual
symptoms of hypoglycemia are: sweating, hunger, shuddering, tachycardia,
confusion, drowsiness, speech difficulty, nausea, headache, tiredness, or
even loss of consciousness. But these aforementioned symptoms vary
according to the age and severity of hypoglycemia (Pearson and
McCrimmon, 2014).
Chapter Two: Review of Literature 38
First aid for sever hyperglycemia was not discussed because it needs
to provide emergent medical supervision by physician only, so that, referring
the child to the hospital to receive proper medication (insulin or anti-diabetic
drugs) is the proper action (Jones, 2012).
Hypoglycemia first aid is done by giving any sugary fluid, grape, or
any sweet chocolate to the victim as soon as possible to reduce risk of shock.
If the child did not respond transferring the case into medical emergency
department is the solution because it might have hyperglycemia or already
entered into shock(Jones, 2012).
A study done in 2012 by Boden et al. on primary school staff concerns
regarding diabetic children cares at school. An interview conducted with 22
primary school staff, and the results revealed teacher’ great fears and
concerns on appropriate diabetes care, and also equals to viewpoints of local
health care providers whom detected the influence of school environment
and family dynamics on care of diabetic kids during school time. Thus, the
conclusion was that the best way to loosen the anxiety and fears toward care
of children with diabetes and also to improve their knowledge and
confidence is to provide training sessions on diabetes (Boden et al., 2012).
Additionally, another work done in 2012 in Turkey by Aycan et al.,
in order to assess teachers’ knowledge on diabetes mellitus and its
management in school. Using a self-administered questionnaire, total 1054
teachers included in the study that lasted for one year. The results showed
that 47.6% of teachers had fair knowledge while 32.4% of them had poorer
level of knowledge, beside that only 625 teachers of total 1054 were alert
that level of blood glucose may decline in diabetic child and needs urgent
care. Hence, teachers who had a child with diabetes, showed better
knowledge. The recommendation of study was to increase extent of such
training programs for teachers and community as whole (Aycan et al., 2012).
Chapter Two: Review of Literature 39
2.5.4. Poisoning:
Childhood food poisoning is an important and common global health
issue, which causes many morbidities and deaths every year. According to
WHO, in 2004 the global deaths due to accidental poisoning were around
346.000 persons and 91% of those deaths were in low or middle income
countries. Additionally, every year nearly 1.5 million cases of childhood
diarrhea caused by contaminated food. Moreover, WHO estimated that about
45.000 deaths occurring every year around the globe in kids and youth below
twenty years of age, which consist around 13% of total poisoning fatalities
(Buzby and Roberts, 2009; Kebriaee-zadeh et al., 2014; Shabestari et al.,
2014; Ansong et al., 2016; Azab et al., 2016).
Food poisoning can be chemical or biological. Thus many definitions
set for food poisoning, according to the causative origins. For instance,
bacterial food poisoning is a poisoning caused by consumption of preformed
toxins in food which results in a toxic morbidity rather than enteric infection,
e.g. food poisoning due to ingestion of Staphylococcus aureus (Kwara,
2016). Another definition defined food poisoning as group of morbidities
resulted from ingestion of foodstuffs contaminated with infectious
microorganism or their toxins or by foods contaminated with chemical (both
metallic or organic) substances (Al-Mazrou, 2004).
According to a study done in 2014, the most common signs and
symptoms of poisoning are neurological (altered consciousness, headache
and vertigo), gastrointestinal (nausea, vomiting, abdominal pain and
diarrhea) and respiratory such as dyspnea (Keka et al., 2014).
First aid for food poisoning preceded by following assessment:
1- Detecting the times that symptoms needed to appear after eating
(immediate or after a while).
2- Knowing the type of food eaten.
3- Asking if any other person became ill.
4- Noticing if patient having diarrhea or vomiting.
Chapter Two: Review of Literature 40
5- Observing the victim for any fever or neurological symptoms (Smeltzer
et al., 2010).
Food poisoning first aid procedures includes: lying the child dawn,
giving lots of fluids (especially water and milk), not inducing vomiting
without medical supervision, providing CPR if needed and the most
important matter seeking for medical attention (National Safety Council,
2004).
A study was conducted in 2010 on students of Taif university in Saudi
Arabia toward knowledge, attitude and practices concerning food poisoning.
The results showed deficit knowledge among more than half of students and
similarly more than half of them responded negatively toward attitude
questions, but the practices questions showed higher scores especially in
hygienic food measure, except of the popular habit of eating meat, rice by
hands and sharing the same cup of soup and milk by several peoples which
can be. Also, the female, were more aware about food poisoning, risk factors
and safety measures (Sharif and Al-Malki, 2010).
Another study was performed in 2014, which evaluated the
knowledge of university students in Istanbul, Turkey, about first aid for
poisoning cases. Total 936 student participated in study, by responding to a
questionnaire formed from twenty-one questions. The results clearly showed
deficit knowledge for most of students except those from medical
disciplines, whom answered the questions correctly due to previous
education and information on first aid. This led to a clear conclusion, that
previous education and knowledge affects knowledge level on first aid. Thus
the study recommended to organize first aid training and educating session
for all students about all first aid issues and not only for poisoning to improve
their knowledge, response and practices in such condition which requiring
first aid (Goktas et al., 2014).
Likewise, another research was conducted in Turkey in 2015, on
mothers’ knowledge about poisoning, in which overall 290 mothers were
Chapter Two: Review of Literature 41
evaluated by a questionnaire consisted from three parts. The results revealed
a clear significant relationship between the poisoning knowledge and
educational level, career and the neighborhood living within (area of living).
The study concluded that the mothers’ knowledge was unsatisfactory and
recommended for future educational meetings and using visual and social
media to increase mothers and families knowledge on poisoning and
protective methods (Sivri and Ozpulat, 2015).
2.6. Section F (literatures regarding burns):
The human discovery for fire was a real revolution and turning point
in human history. Despite of worthy benefits of fire, this discovery was
accompanied by negative effects. These negative effects summoned the
emergence of therapeutic methods and remedies to deal with it. The ancient
Egyptians, Greeks, and Romans doctors contributed in wound care. This
evolution in burn care continued until the early nineteenth century, where
Guillaume Dupuytren developed a burn classification which continued to
our recent days and helped in better dealing with burns, and its’ early
management and treatment (Branski et al., 2012; Pećanac et al., 2013; Baker
et al., 2015).
Worldwide, incidence of burns ranked as fourth among all other
injuries in 2004, and approximately 11 million people were affected by
burns. Luckily, the majority of burn injuries are not fatal, despite of global
mortality that estimated as 300,000 deaths every year due to burns. Likewise,
in middle east countries such as in Turkey the 53.6% of burns incidence
affected children; and so that, in Sulaimaniyah, Iraq the incidence admission
due to burns was 1044 per 100,000 persons, which showed higher incidence
for childhood burns comparing to local population. Another research in
Mosul, Iraq revealed that fatality rate among pediatric burns visited a
hospital in one year was 16.75%, and a similar study in Baghdad showed
that delay of initial car (first aid), ignorance of protection measures,
Chapter Two: Review of Literature 42
especially for children were some reason for high incidence and mortality
among targeted population (Hettiaratchy and Dziewulski, 2004; Carini et al.,
2005; Tarim et al., 2005; Mashreky et al., 2008; Peck, 2011; Lee et al., 2014;
Zubeer and Mohammad, 2014; Othman et al., 2015).
Burns are defined as tissue injuries due to friction, heat, radiation,
chemicals and electricity. Generally, sign and symptom of burns includes:
localized redness, swelling and pain; in sever burn there will be blisters, skin
may peel and appears white or charred, numbness feeling and may be
comprises headache, fever and shock in extreme burns (Krapp, 2002; Longe,
2006).
Burns are categorized into three degrees:
1- 1st
degree burns: causes swelling and redness outer layer of skin
(epidermis).
2- 2nd
degree burns: and comprises swelling, redness and blistering of
skin, and may extend to under layer (dermis).
3- 3rd
degree burns: and also called full thickness burn, which the
entire depth of skin is destroyed and causes scaring; also damage may extend
to fatty layer, muscles or even bones (Ewen and Hart, 2011; Narins, 2013;
Roth and Hughes, 2016).
According to National Safety Council 2004 first aid guide the burns
are in general heat burns, sun burns, inhalational burns, chemical burns and
electrical burns. And first aid for burns detailed as following:
1) 1st
degree burns’ first aid: includes stopping the burning by
removing source of heat, cooling the area by water (within room
temperature) but not icy or very cold to prevent tissue damage, removing any
clothes or other things around affected area before swelling and protecting
the burned area from any pressure or rubbing.
2) 2nd
degree burns’ first aid: included also stopping the burning, then
cooling the area affected (also within room temperature) by immersing small
area in a sink or covering area with wet clothes for at least 10 minutes (but
Chapter Two: Review of Literature 43
must be cautious to not covering most of body) then removing it,
furthermore, removing any jewelry or clothes from region and putting loose
dressing on area to protect it but without letting it stick on burned skin (if
large area affected e.g. face, genitals, legs and arms, don’t wait and transfer
the victim to hospital as quick as possible).
3) 3rd
degree burns’ first aid: and the most serious type of burns
included similarly as aforementioned stopping the burning and cooling the
burned area (around only areas of 1st
and 2nd
degree burns), removing the
clothing and jewelry, calling for medical help and establishing first aid
measures for shock prevention and care, by asking the casualty to lie dawn,
elevating legs and keeping his/her normal body temperature; furthermore,
covering area with clean or sterile dressing and do not put anything on
affected area e.g. oils, lotions and creams (National Safety Council, 2004;
Rosdahl and Kowalski, 2012; Goutos and Tyler, 2013).
In such cases basic life support (BSL) may needed; so that, the victims
breathing must be watched. Be cautious, in third degree burns do not cool
more than 20% of body surface with water for adults and 10% of body
surface for a child, due to high risk of hypothermia and shock. Similarly, as
1st
and 2nd
degree burns anything must not be placed on burn’s area and
furthermore the victim should forbid from drinking any fluids (National
Safety Council, 2004).
A study was conducted in New South Wales to survey the general
population knowledge on first aid for burns. The total number of people
responded to the survey was 7320 persons. The result showed that 82% of
them answered that they will cool the burn with water but only 9% of them
stated that they will continues the cooling for 20 minutes. The study
concluded that most people were unenlightened toward the time needed for
cooling burns, and for steps of first aid needed to deal with burn injury. Thus,
the study recommended for more effort in providing wider and clearer first
aid message to the community (Harvey et al., 2011).
Chapter Two: Review of Literature 44
Graham et al., conducted a study in 2012 in United Kingdom to
evaluate first aid knowledge of burns among parents in south Yorkshire.
Total 188 parent included in the study and responded by structured
questionnaire. Briefly, the results emphasized the needs to develop parents’
awareness on first aid for burns and also the most points of concern showed
by results were, on question about time of cooling a burn, applying correct
dressing and remembering correct first aid steps. (Graham et al., 2012).
Later, another study done in UK 2013 by Davies et al., to assess the
level of information on burns’ first aid among parents. The total number of
parents included in study and responded to the questionnaire was 106, and
the result showed that only 32% of them had acceptable knowledge burns
first aid, while 43% of them had humble or no information on study subject.
Additionally, 40% of respondent had previous training and most of them
(74%) had acceptable knowledge. Totally, the study revealed poor level of
knowledge among the respondents, thus the recommendation by researcher
was to organize training courses for all new parents especially low-income
families (Davies et al., 2013).
2.7. Section G (Literatures Regarding Bites, Foreign Bodies
and Stings):
Choking is defined as accidental inhalation or consumption of foods
or other substances resulting in obstruction of airways and thus suffocation
(Dolkas et al., 2007).
Signs and symptoms for chocking in a conscious child above one year
of age includes: incapability to talk or breath, high-pitched noises,
unproductive coughing and cyanosis (Einzing and Kelly, 2010).
First aid procedures for an aware choking child of more than one
year of age includes:
1- Standing behind the child and wrapping the arms around his/her waist.
Chapter Two: Review of Literature 45
2- Making a fist with one hand and grapping it with other hand, then placing
thumb’s sides of the fist in the middle of child’s abdomen, just below the
sternum.
3- After keeping the elbows out pressing the fist into the child’s abdomen,
quickly for five times, with keeping the child up and without touching the
rib bones (Heimlich Maneuver).
4- Continuing in abdominal thrusts until the child expelling the object.
5- It is important to not interfering if the child was able to cough effectively
or able to talk, and just delivering back blows to help in expelling of foreign
body (Einzing and Kelly, 2010).
Dogs are responsible for 80-90% of bites in children. Besides, it’s
considered as a global problem around the world, which sometimes leads to
death caused by huge trauma, and not to mention, the economic burden of
rabies virus immunization. Due to dog bites nearby fifteen million person
receiving rabies prophylaxis, around the globe. Similarly, human bites
consist 23% of bites cared by doctors. Human bites considered some times
more dangerous than other animal bites due to risk of transmitting infectious
diseases such as Hepatitis B and AIDS (Ambro et al., 2010; Jaindl et al.,
2012; Chaudhuri, 2015; Rothe et al., 2015; Ponsich et al., 2016).
The first aid procedure for animals (e.g. dogs) and human’s bites,
before transferring into hospital includes:
1- If there was no sever bleeding, the wound must be washed by water and
soap then cleaned and covered with sterile gauze.
2- If there was bleeding exist, first of everything must control the bleeding
then referring the child to hospital as soon as possible (Piazza, 2014).
In 2013 a study conducted in India by Kakrani et al., to evaluate the
rural community awareness concerning dog bits’ management. The study
conducted thru interviewing 300 persons were attending with the bits’
victims and lasted for one month. The result of the study showed that only
37.3% of participants were aware that they must observe the dog bit victim
Chapter Two: Review of Literature 46
for ten days after accident, furthermore, 52.1% of participants sensed that
washing of wound with water and soap is useful. Over all persons included
in study precisely 59% of reported that rabies vaccine was expensive for
them. Finally, the study concluded that there was a big gap between
knowledge required and risk presented in area and recommended for
applying more education programs in association with health volunteers
(Kakrani et al., 2013).
After food allergy insect stings considered to be the second reason for
anaphylaxis. According to some reports, up to 2.8% of total severe allergic
reactions in country residence triggered by insect stings. (Fernandez et al.,
2005; Jennings et al., 2010).
Insects or bee stings usually causes pain, redness and swelling around
the site of sting, and its considered harmful than being dangerous. But it
might cause serious allergic reaction, so the victim must be observed for any
allergy symptoms. However, the first aid actions for stings are: removing the
sting if it is visible by scraping or brushing it away by finger nail, then
applying a cold compress and raising the affected part above the level of
heart to minimizing any swelling, during that observing the victim’s vital
signs is important, so that, if any breathing difficulty, itching in skin or
wheezing appeared, should seeking for immediate medical intervention
(Piazza, 2014).
A study conducted in 2016 by Raju in Mysore, India and aimed to
evaluate the effectiveness of structured teaching program on primary school
teachers’ knowledge concerning first aid for insects’ sting and related
preventing measures. A random sample of 60 primary school teachers used,
and an experimental design of single group pre and post-test was applied.
The pre-test results revealed that 6.7% of participants had humble
knowledge, while total 80% of them had moderate knowledge, and only
13.3% of them had respectable knowledge. In post test results the total 65%
of teachers sustained good knowledge and 35% of them had moderate
Chapter Two: Review of Literature 47
knowledge, which shows a significant improvement in their knowledge
toward insect stings prevention and first aid. The study concluded that the
teaching program for teachers regarding first aid was essential for
improvement in their knowledge (Raju, 2016).
2.8. Section K (Literatures Regarding Attitude):
Teacher must take the responsibility and must have the will to deal
with school emergencies because he/she represents the first line in saving
school children’s life during school time. Thus, this matter relates to attitudes
which affects such wish or wills, this also includes teachers acceptance for
child with special needs or chronic illnesses in their classes (Joseph et al.,
2015; Vaz et al., 2015).
Attitudes are well-defined as total evaluations toward some objects
and issues or attitudes are emotion that habitually influenced by human
beliefs, that predispose our responses to objects, persons and occasions. The
relationship between attitudes and action is mutual in which both of them
affecting each other. In brief term attitudes represents subjective evaluation
of our beliefs, behaviors and concepts (Baumeister and Bushman, 2011;
Feldman, 2011; Myers, 2014). There are three component of attitudes,
believe (cognitive component), feeling (affective component) and behavior
(Hewstone et al., 2005).
Attitudes are usually abstracted into three classes of human response
and they are:
- Cognitive: represents our beliefs toward objects or other persons.
- Affective: represents our feeling toward individuals or objects.
- Behavioral: represents our actions toward objects and persons
(Walker et al., 2007).
Attitudes are formed due to numerous influences, and all of them
considered as forms of learning. So that, attitude formed by direct contact,
Chapter Two: Review of Literature 48
direct instructions, interaction with others and indirect conditioning
(observational learning) (Ciccarelli and White, 2015).
Chinese research conducted by Li et al., in 2012 for knowledge and
attitude of preschools’ staff regarding pediatric first aid in Shanghai, China;
and aimed to assess basic level of knowledge and total attitude about first
aid among respondents. A cross-sectional study was performed among staff
of selected preschools by using of stratified random sample. The tool of
study was a multiple choice questionnaire. The research result revealed that
none of 1067 study participants were answered all questions correctly and
just 39 individual (3.7%) carried out successful scores. Particularly,
insufficient knowledge about first aid for epileptic fits detected which only
(16.5%) of them answered such questions correctly. While the correct
answers for eye chemical injuries, inhaled poison, and choking respectively
were 23%, 27%, and 30.1%. Attitude concerning first aid administration was
positive in majority of participants, and most of them felt positively toward
first aid learning and accepted the importance of learning such skills.
Nutshell, these scores carried out using multiple linear regression and
revealed that higher scores were associated with higher education and
previous first aid training. Depending on result of study that showed low
level of knowledge regarding first aid the study concluded that there was an
urgent need to arrange practical educational sessions regarding first aid for
preschools’ staff and undergraduate ones (Li et al., 2012).
Chapter Three
Methodology
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016
Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016

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Knowledge and attitudes of primary school teachers toward first aid in al najaf al-ashraf city thesis 2016

  • 1. Ministry of Higher Education and Scientific Research University of Kufa Faculty of Nursing Knowledge and Attitudes of Primary School Teachers Toward First Aid in Al-Najaf Al-Ashraf City A thesis Submitted to the Council of Faculty of Nursing at University of Kufa in Partial Fulfillment of the Requirements for the Degree of Master in Nursing Science / Community Health Nursing Department By Hussein Mansour Ali Al-Tameemi Supervised by Asst. Prof. Fatima Wanas Khudair B.Sc., MSc., PhD in Community Health Nursing September 2016 A.D. Dhu al-Qi'dah 1437 A.H.
  • 2. ِ‫م‬‫ي‬ِ‫ح‬َّ‫الر‬ ِ‫ن‬َْ‫ْح‬َّ‫الر‬ ِ ‫ه‬‫اّلل‬ ِ‫م‬ْ‫س‬ِ‫ب‬ ﴿‫ا‬ً‫يع‬َِ‫َج‬ َ‫َّاس‬‫ن‬‫ال‬ ‫ا‬َ‫ي‬ْ‫َح‬‫أ‬ ‫ا‬ََّ‫َّن‬َ‫أ‬َ‫ك‬َ‫ف‬ ‫ا‬َ‫اه‬َ‫ي‬ْ‫َح‬‫أ‬ ْ‫ن‬َ‫م‬َ‫و‬﴾ ‫العظيم‬ ‫العلي‬ ‫هللا‬ ‫صدق‬ /‫املائدة‬ ‫{سورة‬‫اآلية‬ ‫من‬ ‫جزء‬32} ‫الما‬ ‫ئدة‬
  • 3. Supervisor Certification I certify that this thesis, which entitled (Knowledge and Attitudes of Primary School Teachers Toward First Aid in Al-Najaf Al-Ashraf City), was prepared under my supervision at the faculty of Nursing, University of Kufa in partial fulfillment of the requirements for the degree of Master in Nursing Science. Supervisor Dr. Fatima Wanas Khudair Asst. Professor and Academic Advisor Faculty of Nursing University of Kufa / / 2016
  • 5. Dedication TO My father and mother with all love and respect. My wife and family with all love and respect. My advisor (Dr.Fatima Wanas Khudair) with all my respect. My dear friends with my love and respect. Primary school teachers who accepted to participant in the study. Hussein
  • 6. I First of all, great thanks for Allah the most merciful the most compassionate, and the prayer and peace of Allah be upon our Master and prophet Muhammad and his divine good family, who guided us to get out of darkness of nescience. Numerous people have helped and supported me in my endeavors. Most especially, I wish to express my deepest and grateful thanks to my supervisor Ass. Professor Dr. Fatima Wanas Khudair, the head of Community Health Nursing branch in the Faculty of Nursing, University of Kufa. I gratefully acknowledge the endless generosity of the experts who kept me on the right track for their time and expertise in reviewing and evaluating of study instrument. I offer my thanks and appreciation to the Directory of Education of Al- Najaf Al-Ashraf, school principals and school teachers for their collaboration during the current study. Also, I would like to recognize the positive efforts and invaluable assistance of the library staff in the Faculty of Nursing. Furthermore, my enduring gratitude goes to my father and mother for their unfailing encouragement, patience, and love. Finally, special thanks to my dear wife, who was a great supporter for me during the most difficult circumstances that I faced, and a great tribute to my kids who were disturbing me during writing this thesis. Acknowledgments
  • 7. II Abstract Background: Unintentional injuries as well as sudden sicknesses is one of the important noteworthy reasons that lead to impairments and mortality in children, particularly those who are in school age. From this standpoint, primary school teachers’ knowledge about first aid is necessary in order to be prepared for providing first aid when needed for children during school time. Methodology: a descriptive cross-sectional study was applied on teachers of governmental primary schools in Al-Najaf city. Furthermore; the study continued from 1st November 2015 to 4th September 2016, in order to assess participants' knowledge and their attitudes toward first aid, as well as, to find any significant relation for teachers socio-demographic characteristic with their knowledge and attitude regarding first aid. By using a simple random sampling, thirty governmental primary schools were selected randomly, and then 320 primary school teachers were selected randomly, through an equation used for determining sample size; finally, the total number of valid questionnaires for analysis were 302. A questionnaire composed of three parts was used, the first part included inquiry regarding socio-demographic characteristic of participants, and the second part included questions concerning knowledge about first aid which was divided into six domains, while the last part included questions regarding teachers' attitudes toward first aid and also it was sub-divided into three domains. Results: The result showed that from total 302 school teachers included in the study, 287 (95%) of them had total fair knowledge and only 15 (5%) of participant teachers had poor knowledge, besides no one of them had good knowledge. With regard to teachers' attitudes towards first aid, the results showed that 282 (93.4%) of the teachers commonly had a positive
  • 8. III attitude toward first aid, while the number of those who owned the negative attitudes towards the first aid did not exceed twenty teachers, about (6.6%) of participants. With respect to the relation of participants’ socio-demographic data with their knowledge levels no significant association was determined but for monthly income, while concerning teachers’ attitudes toward first aid only residency in urban areas and years of experience demonstrated significant relation to their socio-demographic data. Conclusions and Recommendations: the final conclusion and summary of the study showed unsatisfactory knowledge about first aid among teachers, while, participants generally expressed positive attitudes toward first aid. Therefore, the researcher recommended to establish a compulsory training sessions for teachers at the beginning of each academic year.
  • 9. IV List of Contents Subject Page No. Acknowledgements І Abstract ІІ-III List of Contents IV-V List of Tables VI List of Figures VII List of Abbreviations VIII-IX Chapter One: Introduction 1-7 1.1 Background 2-3 1.2 Importance of the Study 4-5 1.3 Statement of the Problem 6 1.4 Objectives of the Study 6 1.5 Definition of the Terms 6-7 Chapter Two: Review of Literatures 8-48 2. Summary for Review of Literature 9 2.1. Section A (Historical Overview): 10-12 2.2. Section B (Literatures Regarding General Information about First Aid): 12-21 2.3. Section C (Literatures Regarding Wounds and Bleeding): 22-27 2.4. Section D (Literatures Regarding Bone and Joint Injuries): 27-32 2.5. Section E (Medical Emergencies and Illnesses): 32-41 2.6. Section F (Literatures Regarding Burns): 41-44 2.7. Section G (Literatures Regarding Bites, Foreign Bodies and Stings): 44-47 2.8. Section K (Literatures Regarding Attitude): 47-48 Chapter Three: Methodology 49-56 3.1. Study Design: 50 3.2. Administrative Arrangements: 50 3.3. Ethical Consideration: 50 3.4. Setting of the Study: 50 3.5. The Sample of the Study: 51 3.5.1. The Sample Size: 51 3.5.2. The Sampling of the Study: 51-52 3.6. Instrument of the Study: 52 3.7. Current Study Validity: 52 3.8. Pilot Study: 53 3.9. Reliability: 53
  • 10. V 3.10. Data Collection: 53-54 3.11. The Statistical Analysis: 54-56 Chapter Four: Results of the Study 57-77 Chapter Five: Discussion of the Study 78-92 5.1. Socio-Demographic Characteristic and Educational Level of Participants: 79-81 5.2. Previous Information on First Aid Among Participants: 81-84 5.3. General Information of Primary School Teachers about First Aid: 84-85 5.4. Teachers’ Knowledge about First Aid for Wounds and Bleeding: 85 5.5. Teachers’ Knowledge about First Aid for Bone and Joint Injuries: 85-86 5.6. Teachers’ Knowledge about First Aid for Medical Conditions: 86-88 5.7. Teachers’ Knowledge about First Aid for Burns: 88 5.8. Teachers’ Knowledge about First Aid for Foreign Bodies (Eyes & Ears), Dog’s Bite and Stings: 88-89 5.9. Teachers’ Overall Knowledge about First Aid: 89-90 5.10. Primary School Teachers’ Attitude Toward First: 90-91 5.11. The Relationship Between Participants’ Overall Knowledge and Attitude Toward First Aid and Their Socio-Demographic Characteristic: 92 Chapter Six: Conclusions and Recommendations 93-96 6.1 Conclusions 94 6.2 Recommendations 94-95 References 96-122 Appendices No. Panel of Experts A Administrative Arrangements B Ethical Considerations C Linguists Certification D Questionnaire in Arabic E Abstract In Arabic
  • 11. VI List of Tables Table No Table Title Page 3.1 Reliability of the current study instrument 53 4.1 Socio-demographic characteristics of the studied group 58 4.2 Educational level and years of experience of the studied group 59 4.3 Distribution of Previous and source of Information about first aid 60 4.4 Responses of participants regarding the general information about first aid 61 4.5 Responses of participants regarding the first aid of Wounds and Bleeding 63 4.6 Responses of participants regarding the first aid of Bone and joint injuries 65 4.7 Responses of participants regarding the first aid of medical situations 67 4.8 Responses of participants regarding the first aid of Burns 69 4.9 Responses of participants regarding the first aid of bites, stings & foreign body 71 4.10 Evaluation of teachers’ overall knowledge about first aid in school 72 4.11 Relationship between overall knowledge of participants and their socio-demographic characteristics 73 4.12 Responses of participant teachers to questions on attitude toward first aid 74 4.13 Frequency distribution of domains and overall attitude toward first aid of participant teachers 75 4.14 Relationship between attitude of participants toward first aid in schools and their socio-demographic characteristics 77
  • 12. VII List of Figures Table No Title of Figure Page 2.1 Priority of Treatment. 15 2.2 First Aid for Nosebleeds. 26 2.3 Types of fractures. 29 2.4.A Fixing with splint only. 31 2.4.B Fixing with both splint and sling. 31 4.1 Distribution of participant teachers according to their knowledge on general information on first aid. 62 4.2 Distribution of participant teachers according to their knowledge on first aids for wounds and bleeding. 64 4.3 Distribution of participant teachers according to their knowledge on first aids for bone and joints injuries. 66 4.4 Distribution of participant teachers according to their knowledge on first aids of medical situations. 68 4.5 Distribution of participant teachers according to their knowledge on first aids of burns. 70 4.6 Distribution of participant teachers according to their knowledge on first aids for bites, stings & foreign bodies. 72 4.7 Distribution of participant teachers according to their attitude toward first aids in schools. 75
  • 13. VIII List of Abbreviations Abbreviation Meaning AAP American Academy of Pediatrics ACEP American College of Emergency Physicians AD Anno Domini AHA American Heart Association AIDS Auto Immune Deficiency Syndrome ANRCS American National Red Cross Society BBB Breathing, Bleeding and Bones BC Before Christ BSL Basic Life Support CD Compact Disk CDC Centers for Disease Control and Prevention CPR Cardio Pulmonary Resuscitation CSO Central Statistical Organization d Level of Significance or Desired Precision D.M Diabetes Mellitus e.g. exempli gratia (Latin Words that Means for example) IQD Iraqi Dinar NCPP National Committee for Population Policies NSC National Safety Council P Estimated Proportion P Page P.P Pages P.value Probability Value q One Minus estimated proportion RICE Rest, Ice, Compression and Evaluation SPSS Statistical Package for the Social Sciences
  • 14. IX TV Television U.K United Kingdom USA United States of America WHO World Health Organization X, 30 Chapter Number from Bible Z Level of Confidence
  • 16. Chapter One: Introduction 2 Chapter One Introduction 1.1. Background: Injuries and sudden illnesses are an essential issue in public health and usually occurring at any times of daily life. Besides, school children injuries take a major part. Unintentional playground injuries occurring during school hours and includes falls, head injuries, wound bleeding and others (Salminen et al., 2014). Accidental injuries are usually categorized based on their happening, for instance: burns, scalds, poisoning, falls and drowning,…etc. (WHO, 2010). They are also exposed to numerous kinds of epidemiological factors in the school which impact their current and upcoming condition of health (Masih et al., 2014). The first aid is an urgent attention delivered to victims of sudden illness or injury until medical helps arrive. So that, early treatment of such emergencies decreases morbidity and deaths among school aged children (Singer et al., 2004; Abdella et al., 2015; Khatatbeh, 2016). A significant part of children’s life is school lifetime, which directly affect their physical and mental health(Thyer, 1996; Olympia et al., 2005). Unfortunately, school health services are ignored in some countries particularly the developing ones. This contributes to shortage in awareness and knowledge regarding sudden illnesses and first aid measures (Bhatia et al., 2009). Children's times mostly spend in school under direct supervision of teachers. Consequently, first-aid should be well-known by teachers who are the key personnel to deal with urgent health needs during school hours. Healthy harmless environment is very vital to avoid these hazards besides competent teachers who can identify any health problem and able to provide first aid for commonly happening emergencies in school (Masih et al., 2014). The 2005 guidelines for first aid definition is “the assessment and interventions that can be performed by a bystander (or by the victim)
  • 17. Chapter One: Introduction 3 immediately with minimal or no medical equipment.” (AHA (American Heart Association ) and ANRCS (American National Red Cross Society), 2005). Another definition adopted in 2014 by American College of Emergency Physicians (ACEP), which refers to first aid as the actions taken in response to somebody who is wounded or has unexpectedly become ill (Piazza, 2014). The primary purpose of first-aid is to reduce suffering, make healing process possible and decrease damage. So that, the first action taken to deal with injuries and sudden illnesses decides the upcoming sequences of illness and complication rates (Goel and Singh, 2008). The National First-aid Science Advisory Board clarified, everybody can and must learn first-aid, i.e. education and training in first-aid should be worldwide. This is recognized by the fact that correctly directed first-aid means the difference among life and death, early versus late rescue, and momentary versus long-lasting disability (Lingard, 2002; Singer et al., 2004; The National First-Aid Advisory Board, 2005). Therefore, teachers must know the basic rules for first aid as well as the students must be instructed on first aid (Uskun et al., 2008; Celik, 2013; Sönmez et al., 2014). Identification of urgent situation and calling for help is an important issue in first aid, particularly in case of lack or insufficient basic knowledge about first aid measures for complex situations to be sure that the child will have a professional medical help (Mahony et al., 2008; Cowan et al., 2010). Teachers are almost the first and the main caregiver represented the first line to protect school children, in addition, teachers’ role complements the parent’s role. School teachers during the school hours, are the real first- respondent to emergencies, injuries resulting from school accidents. Therefore, they have to be capable to act accurately with health emergencies affected the school children (Barrett, 2001; Uskun et al., 2008; Sönmez et al., 2014). Consequently, the current study tried to assess the knowledge and attitude of group of Iraqi primary school teachers in Al-Najaf city.
  • 18. Chapter One: Introduction 4 1.2. Importance of the Study: Unintentional injuries encountered in the childhood are a global public health problem and are to be found as a first order among the causes of mortality and morbidity. Across the world, at least 875 000 children aged below 18 years decease due to unintentional injuries yearly and more than 95% of these deaths happen in countries with low and middle income levels (WHO, 2006; Altunda and Öztürk, 2007; İnanç et al., 2008). For example, in United States of America each year 200,000 schoolchildren are injured during playing and 70% of cases requires hospitalization, moreover, in Europe countries as Poland there were 3274 school accidents reported among 293,000 primary school student every year (Sosnowska and Kostka, 2003; Al-Robaiaay, 2013). Not only injuries but, chronic childhood illnesses may become suddenly an emergency during school period. Schools today contains higher numbers of children with long-lasting and severe illnesses, suffering from diseases like epilepsy, asthma and diabetes mellitus which are requiring special attention and urgent care (Bergren, 2010; Allen et al., 2012). Asthma considered as very public respiratory disorder distressing school children. WHO has reported that worldwide, around 235 million people are asthmatic (Govender and Gray, 2012). Depending on Centers for Disease Control and Prevention (CDC) ten percent of children at USA schools having asthma, while in south Africa asthma affects 20% of schoolchildren (Bergren, 2013; Govender & Gray, 2012). Many researchers recognized impact of teachers’ knowledge on care for asthmatic children. In USA, inappropriate actions of schoolteachers maybe had an essential part in the mortality of school children with asthma between 1990-2003. (Tse, 2002; Greiling et al., 2005; Ones et al., 2006; Govender and Gray, 2012). In addition, diabetes mellitus is another chronic disease affecting children and juveniles, and requires continuous monitoring of affected
  • 19. Chapter One: Introduction 5 children and the teachers can play an important role this case (Aycan et al., 2012; Bergren, 2013). Likewise, epilepsy is one of most commonly neurological childhood problems, mostly observed in first decade of life. Worldwide, there are 33 million child suffering from epilepsy. The intense consequence of having seizure in school can be very hurtful for any child and requires teachers’ first aid knowledge to deal with (Jacoby, 2002; Bishop and Boag, 2006; Aydemir, 2008; Karimi and Heidari, 2015). School children are more susceptible to injuries and carry a greater risk due to developmental and behavioral characteristic including unawareness of hazards and being active as well as bodily properties including narrower airways, smaller body mass and thinner and extra susceptible skin (Peden, 2008). Global studies have noted a diverse depiction around readiness among school teachers to apply first aid. In European studies , for instance, the current philosophy is tending to learn first aid to primary school teachers and they will in turn transfer such skills and knowledge to their pupils , besides, poor knowledge, attitude, practice and awareness among school teachers was observed by many Asian researchers (Bollig et al., 2009; Al-Robaiaay, 2013; Devashish et al., 2013; Kumar et al., 2013; Ammirati et al., 2014). There is a lack in scientifically sound data and only few studies are concerned with this subject in Iraq, in addition, physicians and health care providers are not present in the school (Al-Robaiaay, 2013). Therefore, the assessment of knowledge and attitude of primary schoolteachers and their information regarding first aid will help in establishment of educational programs and workshops about the first aid, that resulting in development of their knowledge and attitude toward first aid with intern reduction in the risk of injuries and enhance life saving for primary school aged children.
  • 20. Chapter One: Introduction 6 1.3. Statement of the Problem: Knowledge and attitudes of primary school teachers toward first aid at Al-Najaf City. 1.4. Objectives of the Study: 1-To assess the level of knowledge and attitude of primary school teachers toward first aid at primary schools of Al-Najaf city. 2- To identify the relationship between the level of knowledge and attitudes of primary school teachers toward first aid and their sociodemographic characteristic (age, gender, residency, marital status, number of children, monthly income, educational level, years of experience, previous information about first aid and sources of previous information). 1.5. Definition of Terms: 1.5.1. Knowledge: a. Theoretical Definition: Information gained through experience or education (Muneeswari, 2014). b. Operational Definition: In this study, the knowledge refers to the ability of teachers to answer the questions correctly and will be measured through self-administered questionnaire. 1.5.2. Attitude: a. Theoretical Definition: The 2015 American Psychological Association dictionary of psychology defined attitude as “a somewhat permanent and overall evaluation of an object, person, group, issue, or concept on a distance ranging from negative to positive”. Attitudes delivers synopsis judgments of target objects which are supposed to be resultant from precise beliefs, feelings, and previous actions accompanied through those objects (VandenBos, 2015). In another words, “attitudes are evaluative reactions
  • 21. Chapter One: Introduction 7 (positive or negative) toward objects, events, and other people” (Griggs, 2012). b. Operational Definition: In this study attitudes recognized in the light of responses of primary school teachers to self-administered questionnaire of five degree Likert scale with taking into account positive and negative formed questions. 1.5.3. Primary School Teacher: a. Theoretical Definition: Primary school teacher is a person who teaches pupils (children under 13 years of age) at the elementary school (Collins English Dictionary, 2016; Merriam-Webster’s Learner’s Dictionary, 2016). b. Operational Definition: Primary school teachers who are existed in primary schools of Al- Najaf city during the period of the study, which they are graduated from teachers' preparation institutes and colleges and working in primary schools in the field of education. 1.5.4. First Aid: a. Theoretical Definition: Emergency measures to help an ill or wounded person preceding to obtaining skillful medical care (Marcovitch, 2009), or in another terms it is “immediate care given to an injured or suddenly ill person, and includes providing momentary help while waiting for competent medical attention, if needed is obtained or until the chance for recovery without medical care is assured” (Thygerson et al., 2011). b. Operational Definition: In the current study, first aid means knowing about injuries requiring initial interventions such as wounds, bleedings, epistaxis, fractures, burns, or electrical shocks, or about sudden illnesses such as epileptic fits, diabetes emergency or asthma attack, and other incidental matters such as dog bites or bug stings, etc.
  • 23. Chapter Two: Review of Literature 9 Chapter two Review of Literature Review of literature is an essential step in research process. It refers to a widespread, exhaustive and systematic examination of different publications related to study issue. Review of literature, is originated from many sources such as books, manuals, previous thesis, dissertation, journal articles, encyclopedias, reports, internet…etc.(Nieswiadomy, 2012). The most vital aim for conducting review of the literature is to identifying any topics known regarding the current study, whereas any former studies are located, and the conceptual framework of the study is formulated. Besides, review of literature is beneficial in planning the methodology of study (Nieswiadomy, 2012). In the current study, review of literature was collected and conducted according to the following: 2.1. Section A: Historical Overview. 2.2. Section B: Literatures regarding general information about first aid. 2.3. Section C: Literatures regarding wounds and bleeding. 2.4. Section D: literatures regarding bone injuries. 2.5. Section E: literatures regarding other medical emergencies and illnesses. 2.6. Section F: literatures regarding burns. 2.7. Section G: literatures regarding bites, foreign bodies and stings. 2.8. Section K: literatures regarding attitude. Additionally, each of aforementioned sections contained a brief historical and epidemiological summary for the relevant subject, besides, a sufficient information on topics of each section and related first aid actions. Furthermore, each section was ended by revealing some previous studies which are related to the heading of section.
  • 24. Chapter Two: Review of Literature 10 2.1. Section A (Historical Overview): First aid skills and expertise as it known today, were recognized back in history but more simply, particularly during warfare (Pearn, 1994).There are many evidence and clues across the ancient civilizations about simple skills used to help injured people instantaneously especially by militaries. For example, a scene painted on a traditional Greek pottery believed to be from 500 years BC, shows the greatest Grecian warrior Achilles from Greek mythology applying bandage to his injured escort Patroclus during the siege of Troy which is an early example for providing first aid without organized medical support (Cotterell, 1996). As further evidence during the bronze age in the middle east, the gospel of St Luke (x, 30) memorialized the good Samaritan ethical values of assisting persons and efficiency of bandaging injured people (Pearn, 1994). Decreasing morbidity and death by applying early first aid, during wars were a big concern for many ancient militaries. The Roman military had the most successful experience for emergency medical services to support their legions, especially under the role of Emperor Augustus (63 BC- 14 AD), who developed such services. The Romans medical services comprised physicians, surgeons, hygiene officers and bandagers whom called capsarii, where they had been wearing the same uniforms for the soldiers, and they trained medically within Legion itself, and because they were on the front lines their ability to provide accurate first aid had been effective. Also they were supported by special units of horses, stretcher- bearers, carriages and wagons to help in transporting wounded soldiers to field hospital (Eastman, 1992; Gabriel and Metz, 1992). A major public concern in the late 18th century directed to the drowning due to high mortality. So that, a society for protecting peoples’ life from water accidents started in Amsterdam 1767, and later in 1773, the physician William Hawes started to publicize the efficiency of artificial
  • 25. Chapter Two: Review of Literature 11 breathing as a way for resuscitation of drowned people, which in turn, led to founding society for drowned persons in 1774 named the Royal Humane Society, which had a major contribution in promoting resuscitation (Collins, 2007; Price, 2014). Hence, the historical roots of first aid as a profession in its own right belongs to about 120 years ago or few more. In which, military surgeons and Royal Humane Society instructions’ contributed in first aid evolution (Pearn, 1994). Later in early 19th century Baron Dominique Jean Larrey, the Napoleon’s famous surgeon created ambulance corps and called flying ambulance in French, in which aimed to provide first aid during battle (Efstathis, 1999). After that, Jean Henri Dunant witnessed the consequence of Solferino battle in 24 June 1859 and his future work led to establishment of Red Cross, which it is still the largest worldwide provider for first aid (Pearn, 1994). Credit goes to the development of first aid to the British Surgeon- Major Peter Shepherd and before him to the Prussian surgeon Friedrich Von Esmarch. In 1870, Friedrich Von Esmarch was the first person who introduced an official organized first aid to the Prussian army and used the term “erste hilfe” which its translation to English means first aid. Also he trained the soldiers to provide first aid including bandaging and splinting skills, for wounded comrades during Franco-Prussian war and designed Esmarch bandage to show the soldiers the accurate way of first aid (Efstathis, 1999). Thereafter, Shepherd noticed the worth and importance of Esmarch’s effort, and his new instructions in bandaging and basic first aid skills. So that, Shepherd quickly developed and extended first aid skills for medical division in British army. In 1878, Surgeon-Major Peter Shepherd with help of Colonel Francis Duncan and doctor Coleman, held the first public first aid
  • 26. Chapter Two: Review of Literature 12 course in Woolwich, London. Soon later, the St John Ambulance Association organized similar classes in other British cities. Consequently, more than one thousand persons had been trained on first aid within a year. The members of St John Ambulance Association were the first people whom used the English term first aid (Pearn, 1994; Efstathis, 1999). It didn’t take so long after the first public first aid classes to test the readiness of community in applying first aid, where after nine month of Shepherd training class Woolwich disasters happened. These two tragedies despite of high rate of deaths, approved the importance of providing first aid by people at site of incidence as possible before transporting the victims or before professional medical helps arrive (Efstathis, 1999). During the 20th century and later 21th century many scientific researches had conducted regarding first aid knowledge and practices (Langley and Silva, 1986; Gagliardi et al., 1994; Conrad and Beattie, 1996; Altintaş et al., 2005; Başer et al., 2007; Yurumez et al., 2007; Al-Robaiaay, 2013; Al-samghan et al., 2015; Khatatbeh, 2016). 2.2. Section B (Literatures Regarding General Information About First Aid): The concept of first aid, since its modern evolution has formulated many definitions. Despite of maintaining the essence of the first aid definition but they began to differ in the built-in as needed, and there became the existence of the first aid in many practical and scientific fields. The field of first aid is affected by both training and regulatory constraints. Therefore, the definition of this scope mutable and could be defined regarding to surrounding circumstances, needs and regulations (Singletary et al., 2015). First aid entered many disciplines and become more advanced and multi diverged such as pediatric first aid, mental health first aid, wilderness first aid, sport first aid, aquatic first aid and so many other disciplines. For example of various definitions of first aid, 2004 manual of first aid definition
  • 27. Chapter Two: Review of Literature 13 was “first aid is the temporary and immediate care given to the person who is injured or suddenly become ill” (Gupta, 2004). Soon later, 2005 California code of regulation defined first aid as “first aid is any one-time treatment and any follow up visit for the purpose of observation of minor scratches, cuts, burns, splinter etc., which do not ordinarily require medical care.” (Kirby and Mather, 2005). The 2010 Guidelines for first aid, stated by American heart association and American red cross defined first aid as “the assessment and interventions that can be performed by a bystander or by the victim (self-care) with minimal or no medical tools.” (Markenson et al., 2010). Later American Academy of Pediatrics set pediatric first aid definition according to their discipline, it was defined as the initial medical care that you give to a child who is injured or suddenly become sick (American Academy of Pediatrics, 2012). After that, American heart association and American red cross updated their definition in 2015 and referred to first aid as assisting activities and immediate care obtained for severing illness or sudden injury with purpose of life’s preservation, suffering alleviation, additional illness or injury deterrence and recovery promotion (Singletary et al., 2015). First aid is complex and situation specific, so that more informed and better trained, first aiders are more eligible to deal with unexpected illness or sudden injury (Saubers and Iannelli, 2008). Thus first aid must be medically sound and based on scientific knowledge, and in absence of such knowledge, the expert must be consulted. First aid can be obtained by everybody and comprises self-care, so that first aider can be any person exist in the scene of emergency and provides such care like parents, teachers, policeman, fireman, first responder, professional medic, etc. (Piazza, 2014; Singletary et al., 2015). There are three main objectives for first aid, firstly to preserve life, not merely victim’s life, but first aider’s life as well. Because if first aider put
  • 28. Chapter Two: Review of Literature 14 his/her life in danger might ends up struggling for his own life instead of the victim’s. Secondly to avoid worsening of condition. The third aim of first aid is to encourage recovery, which means first aider actions should assist injured person toward improvement, certainly after preventing situation from getting worse (Barraclough, 2015). First aider qualifications include the ability to: first aid needs estimation, assessment and prioritization; using suitable knowledge, skills and behaviors to obtain appropriate care; and finally recognition for any limitation and looking for further care when it’s needed (Singletary et al., 2015). The way that the first aider must act during an emergency is an important issue, these actions according to their priorities are: foremost the first aider must make sure that the scene of accident is safe and there are no instant hazards such as fallen electricity lines or hazardous materials; second action is to check for any life threatening conditions (e.g. severe bleeding, breathing difficulties or loss of consciousness); then the first aider should call for emergency medical services and perform Cardio Pulmonary Resuscitation (CPR) if needed and ask for near help if not trained for CPR; after that the first aider must stop any bleeding and check for any head, neck or spinal injury and must not transfer the victim except if it is required (Jones, 2012). The next step in first aider action is to look for any indicators for special health problems such as diabetes mellitus or asthma, through any medications or drug prescriptions, also the first aider must stay calm and quiet during emergency and act quickly to save victim’s life until medical helps arrive. Avoiding direct contact with blood and other bodily fluids if not wearing disposable gloves is an essential matter. Finally the first aider should use proper hand washing technique before and after first aid administration (Jones, 2012).
  • 29. Chapter Two: Review of Literature 15 First aid priority always given to life threatening cases. The (A and B) priority of treatment for any case is to make sure that the airways are open and the victim is breathing normally, and this is called the primary survey, the moment that first aider became sure that the victim is breathing normally the (BBB) is the next priority and it’s given to deal with any bleeding and after that to deal with bone injuries, so that this called secondary survey as in (figure 2.1) (Barraclough, 2015). Figure 2.1. Priority of Treatment. Adopted from First aid made easy manual, by (Barraclough, 2015) Baser et al., 2007 conducted scientific research to evaluate and determine Turkish primary school teachers’ knowledge and attitude concerning first aid. The study sample included three hundred twelve primary school teachers asked on first aid for hemorrhage, epistaxis, wounds, object aspiration and insects’ stings. The study result indicated that the progress of primary school teachers’ age was accompanied with more unlikely first aid practices and attitudes. Finally, study pointed that the knowledge and attitude of primary school teachers toward first aid was
  • 30. Chapter Two: Review of Literature 16 insufficient and recommended for first aid and pediatric basic life support training (Başer et al., 2007). During the same year a study in Poland done by Wisniewski & Majewski 2007 to assess knowledge and attitude about first aid among selected high school teachers in the western Pomerania region. Sample of one hundred school teachers encompassed in this survey from two high schools of two polish cities. The study tool used in this work was a consistent questionnaire used formerly to determine problems of providing first aid among Polish society. The study result showed that despite the fact that the majority of targeted teachers previously had first aid courses, the level of their knowledge required to provide first aid was insufficient. For example, the result indicated that 50% of teachers had theoretical knowledge about rules of providing first aid but only one third of the respondents were able to put these theoretical rules into practice in reality. Also the majority of teachers demonstrated negative attitude toward providing first aid in emergency cases. So that, the study concluded that the training for administering first aid is mandatory for teachers as well as pupils and should be done by medical professional staff, and the study did not omit to mention the importance of changing negative attitude of teachers during first aid session by focusing on ethical value of human assistance (Wiśniewski and Majewski, 2007). Few years later, Ali et al., in 2010 performed an educational training program about first aid for recently graduated nursery school teachers and aimed to develop, implement and evaluate such program about first aid for emergencies happening in preschools. The interventional program included 60 female participants of recently graduates of specific education college, university of Zagazig. The data collection of study divided into three parts, in the first part a questionnaire used to assess teachers’ knowledge regarding first aid, and during second part an educational program implemented on twenty sessions (30 - 45) minute per session, and also participant teachers
  • 31. Chapter Two: Review of Literature 17 were distributed to smaller groups during practical sessions and finally the third part was an evaluation of program by analyzing the pre and post test results of the respondents. Besides an observational check-list used to assess participants first-aid practices regarding wounds, seizure, fractures, epistaxis, burns and choking. The result confirmed that a significant improvement of knowledge and practice from (0 – 10%) at pre-test to (80- 95%) in post-test result scores, which indicated that the program was successful, hence, the study recommended to add first aid practical courses for undergraduate curriculum and periodic training courses for graduated nursery teachers (Ali et al., 2010). During the next year Bildik et al., in 2011 adopted study purposed to define the education faculty students’ level of first aid knowledge and evaluate training administered to them. The study sample encompassed eighty-eight students from university of Gazi, faculty of education in capital Ankara. Almost 20 hours of training for first aid provided completed in 3 months, and pre-test/post-test questionnaire plus final exam performed for participants. Results of the study noticed significant improvement in knowledge and skills after training (Bildik et al., 2011). Hirca 2012 reviewed Turkish literatures regarding first aid, the research entitled “does teachers’ knowledge meets first aid needs of Turkish schools?” and obviously aimed to assess if teachers of Turkish schools having adequate first aid knowledge throughout reviewing preceding articles done in this field in Turkey. The study outcome revealed that the knowledge of Turkish school teachers on first aid was ranging from moderate to unsatisfactory. Most of teachers formerly did not get correct information regarding first aid and even if they had previous training on first aid, it was limited on theoretical sides not practical sides in such sessions. Finally, the study recommended for applying more researches and studies to investigate knowledge of teachers in first aid skills (Hırça, 2012).
  • 32. Chapter Two: Review of Literature 18 Later, in 2013 Al-Robaiaay conducted study on primary school teachers’ knowledge about first aid in Baghdad, Al-Rusafa. The objective of the study included estimation of knowledge of primary school teachers about first aid for situations like fractures and external bleeding and determination effect of years spent on teaching on knowledge levels of teachers and whether there was needs for first aid training or not. A cross-sectional study carried out in several areas in Baghdad, Al-Rusafa over five months and included one hundred primary school teachers (26% of them were science teachers and 22% of them were art and sport teachers). The result showed that only 4% of participants had good knowledge, while 19% of them had fair knowledge but the larger proportion of them (77%) had poor knowledge about first aid. Besides to inadequate knowledge of teachers that concluded by the study, also the study noticed that both years spent in teaching and material taught by teachers had no significant effect on teachers’ knowledge. Al-Robaiaay recommended for regular first aid training and also adding first aid education to syllabus of institutes that prepares future teachers (Al- Robaiaay, 2013). Furthermore, in 2013 Kumar et al., carried out a study aimed at assessing practices and perceptions of school teachers toward first aid, and to find rapport between sociodemographic characteristic and first aid practices, and also to discover any factors that may influence teachers’ perceptions and practices regarding first aid. A cross-sectional study design applied for nine months by using self-administered questionnaire which was tested formerly, and included forty school that selected randomly in city of Mysore. From 262 school teachers involved in the study 57.3% were from urban areas while 42.7% from rural ones, additionally, 49.6% of teachers’ age was above 40 years old. Despite of study results that exposed already 97.3% of selected teachers were heard the term first aid previously, just 78.8% of them comprehended that wounds needs first aid and only 30.2% of them were mindful that fainting needs first aid. So that, the total deduction
  • 33. Chapter Two: Review of Literature 19 referred that teachers’ perceptions and practices regarding first aid is poor and disappointing (Kumar et al., 2013). Devashish et al., in 2013 performed a research to evaluate teachers’ knowledge and practices about first aid, their readiness and if they need first aid training in the city of Vadodara. The study done through cross-sectional design and included 236 school, which two teachers selected from each school (one teacher of physical education and the second teacher from other subjects) and the total number of respondents were 472 teachers (394 males and 78 females), and the study lasted from January 2010 to December 2010. The result of the study showed that just 2.96% of teachers were previously trained on first aid, 14.83% of teachers answered correctly 70% of the questionnaire. Also the authors noticed a significant association between first aid training and better knowledge and also noteworthy association between knowledge score and age, gender, teaching experience and school level (primary, secondary and higher secondary) had been recognized. Generally, paucity in knowledge of teachers detected and based on results of study, the researchers concluded and recommended that first aid training is important and must be regular and updated as well as it must continue throughout teachers’ professional career (Devashish et al., 2013). Sonmez et al., in 2014 conducted a study that aimed to evaluate preschool teachers’ knowledge regarding first aid practices in city of Isparta, Turkey and to identify factors that may affect such levels of knowledge. Total 110 of preschool teachers included in this cross-sectional study by using a questionnaire consisted of 20 points scale. Study result pointed that washing a wound after a dog bite by soap and water and immobilization of fallen child from high altitude were the issues which had lowest knowledge by participants, and their scores were 16.4% and 20.9%, respectively. Additionally, the findings of the study revealed that the age, employment years, previous first aid training and previous experience with situation that
  • 34. Chapter Two: Review of Literature 20 needs first aid had no significant effect on teachers’ levels of knowledge. Likewise, the study detected that participants had poor knowledge and since first aid training did not show noteworthy differences on their knowledge, the researchers inference was that the quality of training need to be received is a fundamental matter (Sönmez et al., 2014). Another study done by Ammirati et al., in 2014 aimed at assessing the knowledge assimilated by children below 6 years of age who were trained by their own teachers and after that comparing the results with another group of untrained children. The study included training teachers on first aid by professional medical emergency staff then 315 pupils selected randomly and divided to 18 classes (nine of them for trained pupils and nine of classes for untrained ones). The majority of trained pupils provided the expected answers, besides the trained group revealed paramount ability to describe emergency situations and had better alert for emergency conditions that needs first aid. The study leveled that those small children were able to assimilate first aid skills taught by teachers and also not forgot to mention that public health goal of trained teachers as well as pupils regarding first aid cannot be reached without providing qualitative education and training to teachers to make them able to transfer such skills and knowledge to others (Ammirati et al., 2014). Shobha Masih et al., in 2014 conducted a quasi-experimental study with one group in Dehradun district of Uttarakhand. The study aimed at evaluating the efficiency of educational program on information of teachers regarding first aid for minor injuries in school children. 50 primary school teachers were selected by convenience sampling, and 94% of selected teachers were female, the result showed that 72% of them experienced previous injuries in school children and 86% of them had no previous training about first aid, but instead of that 74% of them had appropriate knowledge about first aid from other sources like: reading, friends, relatives
  • 35. Chapter Two: Review of Literature 21 and health professionals personnel. The study concluded that the applied program was effective and revealed the further need for such programs to improve the total health standards for school children (Masih et al., 2014). A year later, Al-Samghan et al., in 2015 applied a study to explore the knowledge of primary school teachers regarding first aid. The study was carried out using descriptive/cross-sectional design and included 187 teachers of governmental primary schools of Abha city in Saudi Arabia. A self-administered questionnaire used among participants in boys’ schools only. The result showed that teachers’ mean of age was 41.5+7.4 years and ranged from 25 to 58 years. The result cleared that 28.3% of teachers attended courses on first aid while 62.3% of those had first aid courses reported that these courses included practical training. Moreover, only 31% of them had acceptable knowledge regarding first aid for poisoning, while 52.4% of them had satisfactory scores regarding first aid for bleeding. Overall conclusion of study revealed unsatisfactory knowledge among respondents. So that, the researchers recommended to introduce first aid education and training in curriculum of schools, institutions and colleges, as well as recommended to apply such studies in girls’ primary schools and also secondary schools and declared the obvious need for more researches in this field for future (Al-samghan et al., 2015). Abdella et al., in 2015 performed an interventional program regarding first aid for kindergarten teachers which aimed at evaluating effectiveness of applied program on teachers’ knowledge and practice regarding first aid. Fifty teachers of governmental kindergarten included by using convenience sampling method. In general, and brief term, the result of the study detected significant improvement for both knowledge and practices of involved teachers. The study concluded that the good improvement in teachers scores synthesized by a well-designed program. Moreover, adding first aid learning and training to core curriculum of faculties that prepare future teachers and initiating periodic sessions for first aid to refresh and improve teachers’
  • 36. Chapter Two: Review of Literature 22 information and skills, were recommended by researchers (Abdella et al., 2015). 2.3. Section C (Literatures Regarding Wounds and Bleeding): 2.3.1. Wounds and Bleeding: Human history is full of a lot of evidence on the wound care across civilizations. From clay tablet, which is one of the ancient medical scripts that dates back to 2200 BC which described the three assisting wounds healing steps, and passing through the ancient Egyptian papyruses dating back to 1400 BC, that documented open wounds’ treatment by putting honey and grease into open wounds to improve healing, and even arriving to Hippocrates 400 BC the Greek physician who used piece of tin pipe to inject fluids and to suck pus out of wounds, and so many other examples reaching to our recent days contributed in wound caring and healing, as well as evolution of wound infection prevention (Broughton et al., 2006; Shah, 2011). The breakdown in the skin and underlying tissues causing wounds, as well, Physical injury or mechanical forces (for instance surgical incisions) may result in wounds (Taylor et al., 2011). According to Fundamentals of Nursing Standards and Practice 2011 wounds can be classified according to various terms, but usually described based on the causes. So that, classification based on causes of wounds are: 1- Intentional wounds: occurs due to treatment and usually done under sterile circumstances e.g. surgical incisions. 2- Unintentional wounds: mostly, follows trauma or accident. These wounds are unanticipated and occurs in unsterile situation, which makes risk for infection higher (DeLaune and Ladner, 2011; Sussman and Bates-Jensen, 2012; Berman et al., 2016). Furthermore, another classification set depending on skin integrity, and categorized wounds into:
  • 37. Chapter Two: Review of Literature 23 1- Open wounds: occurs by break of the skin or surgical incision. 2- Closed wounds: may be caused by external blow or crushing and includes internal hemorrhage (Nugent and Vitale, 2014; Burton and Ludwig, 2015) Proper wound care is necessary to promote healing that results in an intact skin layer. Intact skin is the first line of defense of the body against invasion by infectious microorganisms. The skin defends the body in other ways by serving as a sensory organ for pain, touch, and temperature (Bryant and Nix, 2015). First aid procedures for open wounds done through the following steps: First of all, in case of no severe bleeding the wound must cleaned by rinsing it gently under running water with soap to minimize risk of infection and clean the wound then using disinfectants or sanitizers (American Academy of Pediatrics, 2012). Then placing the injured child in proper position, after that, looking at the wound for any foreign bodies. Subsequently, raising the wound site above heart’s level, later, performing direct pressure with disinfected or clean dressing that is enough for covering the wound (Barraclough, 2015). Meticulously, bleeding caused by injury wounds may cause serious threat to the life of casualty, particularly if the amount of blood loss was more than one liter so that techniques used to stop bleeding are an important matter and includes: direct pressure, indirect compression points, and tourniquet (constricting stretchable band that tied strongly above the wound) used to evade massive blood loss (Usman and Davidson, 2014). For direct pressure keeping an eye on the following steps is necessary: 1- Carefully, taking out any foreign body sticking into the wound. 2- Using a sterile or clean bandage and wrapping it gently around the wound and applying direct pressure till the bleeding stops.
  • 38. Chapter Two: Review of Literature 24 3- If the bandage or dressing used very immersed or soaked with blood without removing it, putting more dressing around bleeding site as an alternative. 4- If the bleeding is in arms or legs, raising that part above heart’s level, in order to decreasing blood oozing thru the wound. Pressure points are used in case the direct pressure was ineffective, and the bleeding persists. Thus, the pressure points for body parts in brief terms are as next: - The pressure point for arm bleeding is superior part of arm, below the armpit (axilla). - Forearm pressure point is the inner (interior) part of arm, just under the elbow. - The wrist is the site of pressure point application for hand bleeding. - The pressure point for skull bleeding is the temple (tempora) an area located behind the eyes. - For neck bleeding the pressure applied to carotid vessels which are located a little away from mid-line of neck (Rhoads and Meeker, 2008; Usman and Davidson, 2014). 2.3.2. Epistaxis: The history of providing first aid for epistaxis, backs in date to 5th century BC, which Hippocrates mentioned how to stop nose bleeding, in a time noticed development of scientific medicine in ancient Greek society (Pikoulis et al., 2004; Aydin et al., 2009; Al-azzaawi et al., 2014). Epistaxis refers to the nose bleeding or hemorrhage from the nose and commonly originates in the anterior portion of the nasal cavity (Nettina, 2010). Nose-bleeding is common significant problem which may cause extreme anxiety to the patients and their families; in addition, up to 60% of general population affected by epistaxis for one time at least, which usually can be stopped with simple home remedies or stop on its own without any medical management, but occasionally nose bleeding may be huge and
  • 39. Chapter Two: Review of Literature 25 deadly (Chaiyasate et al., 2005; Mann et al., 2005; Hussain et al., 2006; Kucik and Clenney, 2011; Mcgarry, 2013). Likewise, up to 60% of children suffers from epistaxis for one time at least by age of ten (Davies et al., 2014). Recurrent nose-bleeding due to unknown causes occurs in about 9% of children between age 1 and age 16, and generally is simple and self- limiting but only severe cases referred for professional medical treatment, even though there is no consensus on effective methods to treat epistaxis, besides, epistaxis treatment has undergone important modifications in latest years (Douglas and Wormald, 2007; Qureishi and Burton, 2012; Mcgarry, 2013). Epistaxis or nose bleeding resulted from many causes such as trauma, structural alteration or pathological origins (Ward, 2014). According to Lippincott Manual of Nursing Practice, 2010 these causes can be categorized to: 1- Local causes such as: a. Dryness leading to crust formation and bleeding occurs with removal of crusts by nose picking, rubbing, or blowing. b. Trauma e.g. direct blows. 2- Systemic (pathological) causes which are less common, for example hypertension, arteriosclerosis, renal disease and (bleeding disorders which are most common among systemic causes) (Nettina, 2010). First aid management for epistaxis depends on severity and cause of bleeding but usually includes: 1- Placing the child in an upright position then leaning him/her forward to reduce venous pressure, and asking the child to breathe gently through the mouth to avoid swallowing of blood. 2- compressing the soft part of nostril using index finger and thumb for 5 to 10 minutes to keep pressure on the nasal septum and some first aid guidelines recommends that before applying the pressure to nostril, to ask
  • 40. Chapter Two: Review of Literature 26 the child to blows his/her nose gently to reduce the amount of dried blood before bleeding stops. These two steps presented visually in (figure 2.2). 3- As advanced procedure if the bleeding did not stop a cotton pledget soaked with a vaso-constricting agent then inserted into each nostril, and pressure is applied if bleeding is not controlled by compression alone, after 5 to 10 minutes, the cotton is removed, and the site of bleeding is recognized. Figure 2.2. First Aid for Nosebleeds. Adopted from The Everything First Aid Book by (Saubers, 2008). 4- In case of recurrent epistaxis further medical diagnostic measures and cares needed by referring the child to medical facilities (Nettina, 2010; American Academy of Pediatrics, 2012; Mulla et al., 2012). A postal survey done in 2010 among teachers of local South Wales schools to explore epistaxis rate of recurrence and management in school setting. Total 112 questionnaires were returned from total 157 questionnaires distributed to 116 primary school and 41 secondary school. Therefore, 32 secondary school teacher and 80 elementary school teacher responded to study tool. The results showed that only 25% of secondary teachers and 37.5% of primary teachers were aware on rules of nose bleeding management. The study concluded that notwithstanding of frequently
  • 41. Chapter Two: Review of Literature 27 occurrence of epistaxis in schools, the teachers used incorrect methods to stop epistaxis, in addition to the fact that most epistasis cases stops spontaneously (Robertson, King and Tomkinson, 2010). In 2015 another study conducted by Banafi et al., on prevention of accidents and first aid knowledge for parents of preschools’ students, and included six Hungarian kindergartens. Only 234 self-administered questionnaires obtained from all 307 that were distributed. The study result showed that 74.3% of the respondents faced at least one accident previously, while 74.4% of them had previous training on first aid. As well as, about (3/4) of them (73.5%) answered correctly on epistaxis question, while 18.8% of them reported that the child must lean his/her head backward which makes higher risk for blood aspiration. The highest level of knowledge toward epistaxis and choking matched previous study in Taiwan. Finally, the total knowledge of first aid detected unsatisfactory despite of high scores in choking and epistaxis management. Thus, the researchers recommended to apply a wider survey to detect the population knowledge on first aid and to organize first aid sessions to increase the knowledge about first aid (Bánfai et al., 2015). 2.4. Section D (Literatures Regarding Bone Injuries and Fractures): Human attempts for early care and treatment of fractures and other bone injuries were noticed through the history. Edwin Smith Papyrus (1600 BC) described bandaging of humeral fracture preceded by reduction using traction and also mentioned shoulder dislocation management by reduction. Likewise, many other ancient Egyptian manuscripts referred to approaches for orthopedic surgery established by them. Later, the scripts noted by Greek physician Hippocrates described fracture reduction in detail and noted the bandaging and splinting of fractures. The Roman Celsus (25 BC – 50 AD) described many issues regarding skull fractures and depressed fractures,
  • 42. Chapter Two: Review of Literature 28 some of these issues were founded accurately in comparing with our recent medicine. And so that the mankind history until our days, witnessed many remedies and interventions regarding fractures’ first aid and treatment. (Brorson, 2009; Blomstedt, 2014; Ganz and Arndt, 2014). Globally, the foremost reason of mortality, disability and morbidity among children is injury. As well as, many studies estimated that these common childhood injuries affect about 25% of children annually. According to WHO fractures are the most common types of childhood accidental injuries that affect kids below 15 years of age and necessitates hospitalization in developing countries. In addition, fractures consist about 10 to 25% of all juvenile injuries. Besides, about 3-11% of school children are injured in sport activities during school time (Rennie et al., 2007; Shanmugam and Maffulli, 2008; Khadilkar et al., 2015). A fracture is defined as “an incomplete or complete disruption in the continuity of bone structure” and knew according to its type and extent, and usually fracture occurs when the bone is exposed to a great stress more than its ability to tolerate (Smeltzer et al., 2010); Or in another word, a fracture defined as a loss or shatter of the bone (Judge, 2005; McRae and Esser, 2008; Walker, 2013). Fractures are classified into several types according to many criteria such as mechanism, displacement, pattern, pathology, fragments and location; but generally classified into open and closed fractures (Whiteing, 2008). Open fractures (complex or compound) are defined as fractures in which skin or mucous membrane wound extended to the fractured bone or the fractured bone breakout through the skin, while closed fractures (simple) are defined as fractures in which no skin or tissue disruption occurs by fractured bone (Whiteing, 2008; Dandy and Edwards, 2009; Smeltzer et al., 2010; Wright, 2014)
  • 43. Chapter Two: Review of Literature 29 Common types of open and close fractures (Transverse, Oblique, Spiral, Comminuted, Avulsion, Impacted, Fissure and Greenstick) are showed in figure (2.3). Figure 2.3 Types of fractures. Adopted from Orthopedic and Trauma Nursing by (Clarke & Santy-Tomlinson 2014). First aid intervention for musculoskeletal injuries such as fractures, sprains or even strains generally includes the principle of RICE, which means the following: - “R” refers to REST: and means the injury must be placed in rest (comfort) situation and any effort should be banned, e.g. don’t allow the child play or move by his/her own on injured area or even the first aider must be cautious to keep his weight away from injury site and not move the bone to prevent fragmentation of bone (Dvorchak, 2010; American Academy of Pediatrics, 2012; Barraclough, 2015). - “I” refers to ICE: and means that an ice or cold pack should be placed on site of injury to help in vasoconstriction of blood vessels and thus will help in reducing swelling; this must be applied as soon as possible for 10 minutes and should be repeated every 2 hours for 24 hours or 48 hours as maximum (Saubers and Iannelli, 2008; Barraclough, 2015). - “C” refers to COMPRESSION: and means necessity of using an elastic or firm bandage to injured musculoskeletal area (Piazza, 2014; Barraclough, 2015).
  • 44. Chapter Two: Review of Literature 30 - “E” refers to ELEVATION: and means the affected area must be elevated to reduce swelling specially in joint injury (Barraclough, 2015). The first aider must keep in his/her mind some important notes such as: never attempt to straighten a knee joint by force and never try to align the ends of an open fracture, and also don’t give the casualty any fluids or foods, because a surgery may be needed. Furthermore, the affected area must not be rubbed, and the joint below and above fracture must be immobilized (Meredith, 2006; Dvorchak, 2010). The immobilization done by using splints or slings or both as needed and according to fracture’s type or site Figure (2.4), the splints used to immobilize the joint below an above fracture and it should be firm, lengthy and wide enough for fixing the joint below and above the fracture and prevent any movement immediately, and it may be an umbrella, piece of wood or even a rifle, while the sling made of triangular or roller bandage and used to immobilize some parts of body such as jaw, collar bones or limbs and the slings may be spontaneously selected from surroundings area of injury, it may be a belt, shoe lace, piece of cloth or even neck ties (Karesh, 2012; Gloster and Johnson, 2016). The fracture’s intervention is differing in detail according to location and type of fracture, thus first aid for neck, head, legs, arms, fingers, pelvis, ribs, spinal cord and other types of fractures are the same in general principle, but may contrast in detail and type of interventions needed. Therefore, dealing with different fractures in depth, needs first aider provided with proper training and knowledge on first aid.
  • 45. Chapter Two: Review of Literature 31 Figure 2.4 A. Fixing with splint only B. Fixing with both splint and sling. Adopted from First Aid for Nurses by (Karesh, 2012). Another common musculoskeletal injury among school aged children are sprains, which are relates directly to early engagement in sport activities since primary stages of their life, and increased principally during last years as a way for improving body fitness , which makes risk for injury more factual (Caine et al., 2008; Gottschalk and Andrish, 2011; Doherty et al., 2014; Dorje et al., 2014). Globally, almost one ankle sprain occurs in everyday per ten thousand persons (Waterman et al., 2010). Sprains are defined as injuries to ligament, which are band of tissues that hold bones in position and connect them to other bones or to the joints. Common signs and symptoms of sprain are: pain and tenderness, fast swelling of area, discoloration of skin and bruising in area. Concisely, emergency first aid for sprains includes immobilization, elevation, application of cool pack and referring to a health facility for further professional medical care (Jones, 2012; Flegel, 2014; Stephens, 2016). Sundblad et al., in 2005 conducted a study about injuries of school children during physical activities. The outcome of study showed that most common kind of injuries among study population were strains and sprains (49% of all injuries), while the wounds made only 14%. However, the rate incidence for fractures were 5%, for dislocations 4% and for concussions
  • 46. Chapter Two: Review of Literature 32 5%. As well, 33% of injured children were attended by parents or other grownup household member, while the class teachers and sport trainers cared for 26% of all incidence. Besides, the physicians and school nurses cared 17% and 24% of all injuries, respectively. This study revealed the importance of providing first aid training and increasing related knowledge for class teachers, educators and sport coaches, because the school teachers are the first persons which confronting child emergencies at school (Sundblad et al., 2005). Albrecht & Strand in 2010 applied a survey study on sport coaches’ knowledge and qualification concerning first aid. From total 594 of school coaches participated the study only 154 completed the survey questionnaire that was consisted from four sections about first aid for injuries and sudden illnesses, as well as questions about CPR/AED. So that, the results revealed higher knowledge and confidence when confronting an emergency for teachers with first aid certification in comparing to those without certification. Thus, the researchers underlined the importance of giving official and high quality training for school sport teachers (Albrecht and Strand, 2010). 2.5. Section E (Literatures Regarding Other Medical Emergencies and Illnesses): 2.5.1. Asthma: The historical chronicles denoted that the ancient Chinese and Egyptians were the first nations who treated asthma. But the origins of the word asthma back in date into Greek term “aazein” which its literal translation into English means “to pant or exhale with open mouth”.(Gordon, 2008; Singh and Singh, 2014; Bhattacharjee et al., 2015; Tanaka, 2015). Asthma is considered as very common respiratory disorders, and higher level for asthma incidence recorded throughout the last decades. Likewise, asthma is a world challenging health problem, which according to
  • 47. Chapter Two: Review of Literature 33 WHO it affects around 235 million persons around the globe and annually kills more than 180.000 person, and as well as global childhood mortality due to asthma range between 0.0 to 0.7 per 100.000 every year. Furthermore, the children are the most age group influenced by asthma which is most common chronic childhood illness especially between ages of 5 to 14 years (Subbarao et al., 2009; WHO, 2013; Asher and Pearce, 2014). Asthma is defined as chronic airway inflammation or increased airway responsiveness that leads to dyspnea, wheezing and coughing or even variable airway obstruction (Innes and Maxwell, 2016). Sign and symptom of asthma attack generally are: productive cough, dyspnea, using accessory respiration muscles, tachycardia, tachypnea and noticeable expiratory wheezing (Japp and Robertson, 2013; Linton, 2016) The factors that increase risk of asthma attack and considered as triggers (acute asthma exacerbations) are: 1- air pollution. 2- allergens such as dust. 3- exercise (exercise induced asthma). 4- hormones (in females during menstruation). 5- occupational. 6- psychological.(Greener, 2015). Asthma first aid management includes following actions: 1- First of anything giving the medication of asthma that the child brought with him. 2- Remain providing inhaler, one puff per minute. 3- Putting the child in a comfortable position which makes breathing easier to him (sit him/her upright or lean forward). 4- Loosen the child’s clothes to ease the breathing. 5- helping the child to breath slowly (inhale/exhale).(McMurray, 2011). A pilot study conducted in 2012 in a rural school in Illinois, USA by Lucas et al. about primary school teachers’ knowledge concerning asthma care in children. The questionnaire used contained common information on asthma and its related management. The result revealed insufficient knowledge among the respondents, besides, the result noticed that teachers
  • 48. Chapter Two: Review of Literature 34 were not ready to deliver asthma care. Thus, the researchers recommended to educate teachers on health issues and any cares needed, to insure protection of kids during class period (Lucas et al., 2012). A prospective, cross-sectional research conducted in Quetta, Pakistan in 2015 by Aqeel et al., in order to assess teachers’ knowledge and awareness toward asthma and factors that may increase the risk for asthma attacks. The study concluded that a training programs needed to improve teachers’ knowledge about asthma symptoms and proper care needed in asthma emergency situations. Thus, researches recommended to organize such sessions and programs in Quetta, Pakistan to ensure pupils health safety during school time (Aqeel et al., 2015). 2.5.2. Epilepsy: The earliest description of epilepsy backs in date to Akkadian civilization in ancient Mesopotamia around 2000 BC. In nutshell, the contribution of ancient Iraqi civilization about epilepsy description, diagnosis and treatment was very clear, in spite of it connectedness to many myths. The real origin of word epilepsy that is used in our time relates to Greek verb (epilambanein), which means “possess, distress or to take hold of”. These studies continued since antiquity and until it developed in our recent times due to huge progression and discoveries in medicine (Devinsky and Lai, 2008; Magiorkinis et al., 2010; Wang et al., 2011; Magiorkinis et al., 2014). Epilepsy is one of the oldest and common non-communicable disease, affecting nearly 50 million persons around the globe, and it’s expected to increase every year. The global childhood incidence of active epilepsy estimated around 10.5 million children, which represents 25% of total epilepsy population around the globe. What makes epilepsy an important issue, is that the most age group vulnerable to injury due to epilepsy are children; and as it known negative effect of epilepsy on personal life it’s also severely influences the social life of epileptic children and thus their quality
  • 49. Chapter Two: Review of Literature 35 of life in home, schools, community, etc.(Calisir et al., 2006; Guerrini, 2006; De-Boer et al., 2008; Ngugi et al., 2010; Camfield and Camfield, 2015; Davidson et al., 2016). Epilepsy classified into generalized and partial. Also, the partial epilepsy classified into simple and complex, while generalized epilepsy categorized into tonic-clonic, absence, myoclonic jerks, tonic and atonic seizures (Glasper et al., 2015; Harrisson, 2016). Clinical features of seizures influenced by: brain parts affected (one part or more), pattern of spread of through the brain, age and epilepsy etiology (Glasper et al., 2015). Management of seizure differs according to types, but generally the first aid actions for epilepsy are as next: 1- Protecting epileptic child from injury, by removing any close harmful stuffs especially in generalized seizures. 2- Supporting the victim’s head, by placing billow, towel, blanket, soft pad or folded clothes under the head. 3- Placing piece of wood or anything between the teeth to prevent him/her from biting the tongue. 4- loosen the tied clothes to ease the breathing. 5- Turning the victim on his/her side if there was fluid getting out from the mouth (milk, blood or saliva) in order to drain the fluid out. 6- Observing the child until the seizure ends then putting the child in recovery position for a while until breath normally and be more conscious. 7- If the child became blue CPR must be provided. 8- The first aider must never attempt to hold or replace the epileptic victim (American National Red Cross, 2007; O’Hara, 2007; AAP, 2012). In 2013 a community based research conducted on knowledge, attitude and perception of secondary school teachers in Osogbo, Nigeria. The study results showed there was a shortage in their knowledge about first aid actions. Generally, a positive attitude noticed among most of teachers. The
  • 50. Chapter Two: Review of Literature 36 study recommended for educational courses on epilepsy and other illnesses in classroom and also on emergency measures needed for such conditions (Mustapha et al., 2013). A planned teaching program aboutknowledge and attitude on epilepsy and its related first aid actions among primary school teachers in Nagpur city in India and done in 2016. The result showed that there was no significant relation between first aid management and knowledge and attitude toward epilepsy, while a significant association founded for age, gender and teaching experience with both teachers first aid management of epilepsy and teachers knowledge and attitude toward epilepsy. The conclusion of researcher based on the results was that the program was successful (Wagh, 2016). 2.5.3. Diabetes Mellitus: The physicians in ancient Egypt 3500-2000 BC identified the symptoms of diabetes mellitus (D.M). However, the origins of (Diabetes Mellitus) is ancient Greece, which the word diabetes means siphon (running through) and the word mellitus means sugarcoated or sweet. Nutshell, the all ancient Egypt, Chinese, Greece, Rome, and Indian considered diabetes as a significant morbidity. As well, the famous Muslim physician Avicenna was the first one who confirmed the sweet characteristic of diabetic urine (King and Rubin, 2003; Eknoyan, 2006; Dupras et al., 2010; Zhang et al., 2010; Laios et al., 2012). Diabetes mellitus had become a worldwide chronic epidemic in spite the fact that it is not a communicable disease, but due to high incidence and prevalence rates. WHO estimation for D.M cases in 2000 was 154 million persons and founded to be 246 million in 2006, furthermore, by 2025 prospected to be 380 million persons. In middle-east and north African district, the disease estimated to be almost 9.2% of populations (34 million), and 17 million of them non diagnosed persons, furthermore, in middle-east only approximately 60.000 cases younger than fifteen years old founded to
  • 51. Chapter Two: Review of Literature 37 have diabetes type1 every year. Moreover, in 2013 the mortality of D.M estimated to be about 4% of all mortality reasons, and it consist the fifth leading cause of death in Arab world countries and other Asian states like Korea (Levitt, 2008; Kim, 2011; Majeed et al., 2014; Abuyassin and Laher, 2016; Zayed, 2016). Diabetes mellitus is a disorder resulted from lack or absence of insulin production by pancreas or existence of factors opposing the insulin works (Watkins, 2003; Rosdahl and Kowalski, 2012). Diabetes mellitus is classified into: insulin dependent (type 1 DM) which usually affects the children, non-insulin dependent (type 2 DM) usually affects the adults, gestational diabetes mellitus(which occurs during pregnancy) and other types like diabetes insipidus, prediabetes (LeMone et al., 2011; Rosdahl and Kowalski, 2012). All types of diabetes of mellitus are causing hyperglycemia (increasing blood glucose levels), thus, the major symptoms of hyperglycemia are: polyuria, polydipsia (thirst and dry mouth), nocturia (frequent nightly urination), fatigue, lethargy, muddling of vision, polyphagia (especially for sweets) and sometimes headache, nausea and irritability (Pearson and McCrimmon, 2014). Besides the hyperglycemia that caused by diabetes and needs management, occasionally hypoglycemia (decreasing blood sugar levels) occurs which is resulted due to many causes such as excessive diabetes drug dose, or excessive exercise or during night sleep and considered as life threatening condition even more than hyperglycemia, and most usual symptoms of hypoglycemia are: sweating, hunger, shuddering, tachycardia, confusion, drowsiness, speech difficulty, nausea, headache, tiredness, or even loss of consciousness. But these aforementioned symptoms vary according to the age and severity of hypoglycemia (Pearson and McCrimmon, 2014).
  • 52. Chapter Two: Review of Literature 38 First aid for sever hyperglycemia was not discussed because it needs to provide emergent medical supervision by physician only, so that, referring the child to the hospital to receive proper medication (insulin or anti-diabetic drugs) is the proper action (Jones, 2012). Hypoglycemia first aid is done by giving any sugary fluid, grape, or any sweet chocolate to the victim as soon as possible to reduce risk of shock. If the child did not respond transferring the case into medical emergency department is the solution because it might have hyperglycemia or already entered into shock(Jones, 2012). A study done in 2012 by Boden et al. on primary school staff concerns regarding diabetic children cares at school. An interview conducted with 22 primary school staff, and the results revealed teacher’ great fears and concerns on appropriate diabetes care, and also equals to viewpoints of local health care providers whom detected the influence of school environment and family dynamics on care of diabetic kids during school time. Thus, the conclusion was that the best way to loosen the anxiety and fears toward care of children with diabetes and also to improve their knowledge and confidence is to provide training sessions on diabetes (Boden et al., 2012). Additionally, another work done in 2012 in Turkey by Aycan et al., in order to assess teachers’ knowledge on diabetes mellitus and its management in school. Using a self-administered questionnaire, total 1054 teachers included in the study that lasted for one year. The results showed that 47.6% of teachers had fair knowledge while 32.4% of them had poorer level of knowledge, beside that only 625 teachers of total 1054 were alert that level of blood glucose may decline in diabetic child and needs urgent care. Hence, teachers who had a child with diabetes, showed better knowledge. The recommendation of study was to increase extent of such training programs for teachers and community as whole (Aycan et al., 2012).
  • 53. Chapter Two: Review of Literature 39 2.5.4. Poisoning: Childhood food poisoning is an important and common global health issue, which causes many morbidities and deaths every year. According to WHO, in 2004 the global deaths due to accidental poisoning were around 346.000 persons and 91% of those deaths were in low or middle income countries. Additionally, every year nearly 1.5 million cases of childhood diarrhea caused by contaminated food. Moreover, WHO estimated that about 45.000 deaths occurring every year around the globe in kids and youth below twenty years of age, which consist around 13% of total poisoning fatalities (Buzby and Roberts, 2009; Kebriaee-zadeh et al., 2014; Shabestari et al., 2014; Ansong et al., 2016; Azab et al., 2016). Food poisoning can be chemical or biological. Thus many definitions set for food poisoning, according to the causative origins. For instance, bacterial food poisoning is a poisoning caused by consumption of preformed toxins in food which results in a toxic morbidity rather than enteric infection, e.g. food poisoning due to ingestion of Staphylococcus aureus (Kwara, 2016). Another definition defined food poisoning as group of morbidities resulted from ingestion of foodstuffs contaminated with infectious microorganism or their toxins or by foods contaminated with chemical (both metallic or organic) substances (Al-Mazrou, 2004). According to a study done in 2014, the most common signs and symptoms of poisoning are neurological (altered consciousness, headache and vertigo), gastrointestinal (nausea, vomiting, abdominal pain and diarrhea) and respiratory such as dyspnea (Keka et al., 2014). First aid for food poisoning preceded by following assessment: 1- Detecting the times that symptoms needed to appear after eating (immediate or after a while). 2- Knowing the type of food eaten. 3- Asking if any other person became ill. 4- Noticing if patient having diarrhea or vomiting.
  • 54. Chapter Two: Review of Literature 40 5- Observing the victim for any fever or neurological symptoms (Smeltzer et al., 2010). Food poisoning first aid procedures includes: lying the child dawn, giving lots of fluids (especially water and milk), not inducing vomiting without medical supervision, providing CPR if needed and the most important matter seeking for medical attention (National Safety Council, 2004). A study was conducted in 2010 on students of Taif university in Saudi Arabia toward knowledge, attitude and practices concerning food poisoning. The results showed deficit knowledge among more than half of students and similarly more than half of them responded negatively toward attitude questions, but the practices questions showed higher scores especially in hygienic food measure, except of the popular habit of eating meat, rice by hands and sharing the same cup of soup and milk by several peoples which can be. Also, the female, were more aware about food poisoning, risk factors and safety measures (Sharif and Al-Malki, 2010). Another study was performed in 2014, which evaluated the knowledge of university students in Istanbul, Turkey, about first aid for poisoning cases. Total 936 student participated in study, by responding to a questionnaire formed from twenty-one questions. The results clearly showed deficit knowledge for most of students except those from medical disciplines, whom answered the questions correctly due to previous education and information on first aid. This led to a clear conclusion, that previous education and knowledge affects knowledge level on first aid. Thus the study recommended to organize first aid training and educating session for all students about all first aid issues and not only for poisoning to improve their knowledge, response and practices in such condition which requiring first aid (Goktas et al., 2014). Likewise, another research was conducted in Turkey in 2015, on mothers’ knowledge about poisoning, in which overall 290 mothers were
  • 55. Chapter Two: Review of Literature 41 evaluated by a questionnaire consisted from three parts. The results revealed a clear significant relationship between the poisoning knowledge and educational level, career and the neighborhood living within (area of living). The study concluded that the mothers’ knowledge was unsatisfactory and recommended for future educational meetings and using visual and social media to increase mothers and families knowledge on poisoning and protective methods (Sivri and Ozpulat, 2015). 2.6. Section F (literatures regarding burns): The human discovery for fire was a real revolution and turning point in human history. Despite of worthy benefits of fire, this discovery was accompanied by negative effects. These negative effects summoned the emergence of therapeutic methods and remedies to deal with it. The ancient Egyptians, Greeks, and Romans doctors contributed in wound care. This evolution in burn care continued until the early nineteenth century, where Guillaume Dupuytren developed a burn classification which continued to our recent days and helped in better dealing with burns, and its’ early management and treatment (Branski et al., 2012; Pećanac et al., 2013; Baker et al., 2015). Worldwide, incidence of burns ranked as fourth among all other injuries in 2004, and approximately 11 million people were affected by burns. Luckily, the majority of burn injuries are not fatal, despite of global mortality that estimated as 300,000 deaths every year due to burns. Likewise, in middle east countries such as in Turkey the 53.6% of burns incidence affected children; and so that, in Sulaimaniyah, Iraq the incidence admission due to burns was 1044 per 100,000 persons, which showed higher incidence for childhood burns comparing to local population. Another research in Mosul, Iraq revealed that fatality rate among pediatric burns visited a hospital in one year was 16.75%, and a similar study in Baghdad showed that delay of initial car (first aid), ignorance of protection measures,
  • 56. Chapter Two: Review of Literature 42 especially for children were some reason for high incidence and mortality among targeted population (Hettiaratchy and Dziewulski, 2004; Carini et al., 2005; Tarim et al., 2005; Mashreky et al., 2008; Peck, 2011; Lee et al., 2014; Zubeer and Mohammad, 2014; Othman et al., 2015). Burns are defined as tissue injuries due to friction, heat, radiation, chemicals and electricity. Generally, sign and symptom of burns includes: localized redness, swelling and pain; in sever burn there will be blisters, skin may peel and appears white or charred, numbness feeling and may be comprises headache, fever and shock in extreme burns (Krapp, 2002; Longe, 2006). Burns are categorized into three degrees: 1- 1st degree burns: causes swelling and redness outer layer of skin (epidermis). 2- 2nd degree burns: and comprises swelling, redness and blistering of skin, and may extend to under layer (dermis). 3- 3rd degree burns: and also called full thickness burn, which the entire depth of skin is destroyed and causes scaring; also damage may extend to fatty layer, muscles or even bones (Ewen and Hart, 2011; Narins, 2013; Roth and Hughes, 2016). According to National Safety Council 2004 first aid guide the burns are in general heat burns, sun burns, inhalational burns, chemical burns and electrical burns. And first aid for burns detailed as following: 1) 1st degree burns’ first aid: includes stopping the burning by removing source of heat, cooling the area by water (within room temperature) but not icy or very cold to prevent tissue damage, removing any clothes or other things around affected area before swelling and protecting the burned area from any pressure or rubbing. 2) 2nd degree burns’ first aid: included also stopping the burning, then cooling the area affected (also within room temperature) by immersing small area in a sink or covering area with wet clothes for at least 10 minutes (but
  • 57. Chapter Two: Review of Literature 43 must be cautious to not covering most of body) then removing it, furthermore, removing any jewelry or clothes from region and putting loose dressing on area to protect it but without letting it stick on burned skin (if large area affected e.g. face, genitals, legs and arms, don’t wait and transfer the victim to hospital as quick as possible). 3) 3rd degree burns’ first aid: and the most serious type of burns included similarly as aforementioned stopping the burning and cooling the burned area (around only areas of 1st and 2nd degree burns), removing the clothing and jewelry, calling for medical help and establishing first aid measures for shock prevention and care, by asking the casualty to lie dawn, elevating legs and keeping his/her normal body temperature; furthermore, covering area with clean or sterile dressing and do not put anything on affected area e.g. oils, lotions and creams (National Safety Council, 2004; Rosdahl and Kowalski, 2012; Goutos and Tyler, 2013). In such cases basic life support (BSL) may needed; so that, the victims breathing must be watched. Be cautious, in third degree burns do not cool more than 20% of body surface with water for adults and 10% of body surface for a child, due to high risk of hypothermia and shock. Similarly, as 1st and 2nd degree burns anything must not be placed on burn’s area and furthermore the victim should forbid from drinking any fluids (National Safety Council, 2004). A study was conducted in New South Wales to survey the general population knowledge on first aid for burns. The total number of people responded to the survey was 7320 persons. The result showed that 82% of them answered that they will cool the burn with water but only 9% of them stated that they will continues the cooling for 20 minutes. The study concluded that most people were unenlightened toward the time needed for cooling burns, and for steps of first aid needed to deal with burn injury. Thus, the study recommended for more effort in providing wider and clearer first aid message to the community (Harvey et al., 2011).
  • 58. Chapter Two: Review of Literature 44 Graham et al., conducted a study in 2012 in United Kingdom to evaluate first aid knowledge of burns among parents in south Yorkshire. Total 188 parent included in the study and responded by structured questionnaire. Briefly, the results emphasized the needs to develop parents’ awareness on first aid for burns and also the most points of concern showed by results were, on question about time of cooling a burn, applying correct dressing and remembering correct first aid steps. (Graham et al., 2012). Later, another study done in UK 2013 by Davies et al., to assess the level of information on burns’ first aid among parents. The total number of parents included in study and responded to the questionnaire was 106, and the result showed that only 32% of them had acceptable knowledge burns first aid, while 43% of them had humble or no information on study subject. Additionally, 40% of respondent had previous training and most of them (74%) had acceptable knowledge. Totally, the study revealed poor level of knowledge among the respondents, thus the recommendation by researcher was to organize training courses for all new parents especially low-income families (Davies et al., 2013). 2.7. Section G (Literatures Regarding Bites, Foreign Bodies and Stings): Choking is defined as accidental inhalation or consumption of foods or other substances resulting in obstruction of airways and thus suffocation (Dolkas et al., 2007). Signs and symptoms for chocking in a conscious child above one year of age includes: incapability to talk or breath, high-pitched noises, unproductive coughing and cyanosis (Einzing and Kelly, 2010). First aid procedures for an aware choking child of more than one year of age includes: 1- Standing behind the child and wrapping the arms around his/her waist.
  • 59. Chapter Two: Review of Literature 45 2- Making a fist with one hand and grapping it with other hand, then placing thumb’s sides of the fist in the middle of child’s abdomen, just below the sternum. 3- After keeping the elbows out pressing the fist into the child’s abdomen, quickly for five times, with keeping the child up and without touching the rib bones (Heimlich Maneuver). 4- Continuing in abdominal thrusts until the child expelling the object. 5- It is important to not interfering if the child was able to cough effectively or able to talk, and just delivering back blows to help in expelling of foreign body (Einzing and Kelly, 2010). Dogs are responsible for 80-90% of bites in children. Besides, it’s considered as a global problem around the world, which sometimes leads to death caused by huge trauma, and not to mention, the economic burden of rabies virus immunization. Due to dog bites nearby fifteen million person receiving rabies prophylaxis, around the globe. Similarly, human bites consist 23% of bites cared by doctors. Human bites considered some times more dangerous than other animal bites due to risk of transmitting infectious diseases such as Hepatitis B and AIDS (Ambro et al., 2010; Jaindl et al., 2012; Chaudhuri, 2015; Rothe et al., 2015; Ponsich et al., 2016). The first aid procedure for animals (e.g. dogs) and human’s bites, before transferring into hospital includes: 1- If there was no sever bleeding, the wound must be washed by water and soap then cleaned and covered with sterile gauze. 2- If there was bleeding exist, first of everything must control the bleeding then referring the child to hospital as soon as possible (Piazza, 2014). In 2013 a study conducted in India by Kakrani et al., to evaluate the rural community awareness concerning dog bits’ management. The study conducted thru interviewing 300 persons were attending with the bits’ victims and lasted for one month. The result of the study showed that only 37.3% of participants were aware that they must observe the dog bit victim
  • 60. Chapter Two: Review of Literature 46 for ten days after accident, furthermore, 52.1% of participants sensed that washing of wound with water and soap is useful. Over all persons included in study precisely 59% of reported that rabies vaccine was expensive for them. Finally, the study concluded that there was a big gap between knowledge required and risk presented in area and recommended for applying more education programs in association with health volunteers (Kakrani et al., 2013). After food allergy insect stings considered to be the second reason for anaphylaxis. According to some reports, up to 2.8% of total severe allergic reactions in country residence triggered by insect stings. (Fernandez et al., 2005; Jennings et al., 2010). Insects or bee stings usually causes pain, redness and swelling around the site of sting, and its considered harmful than being dangerous. But it might cause serious allergic reaction, so the victim must be observed for any allergy symptoms. However, the first aid actions for stings are: removing the sting if it is visible by scraping or brushing it away by finger nail, then applying a cold compress and raising the affected part above the level of heart to minimizing any swelling, during that observing the victim’s vital signs is important, so that, if any breathing difficulty, itching in skin or wheezing appeared, should seeking for immediate medical intervention (Piazza, 2014). A study conducted in 2016 by Raju in Mysore, India and aimed to evaluate the effectiveness of structured teaching program on primary school teachers’ knowledge concerning first aid for insects’ sting and related preventing measures. A random sample of 60 primary school teachers used, and an experimental design of single group pre and post-test was applied. The pre-test results revealed that 6.7% of participants had humble knowledge, while total 80% of them had moderate knowledge, and only 13.3% of them had respectable knowledge. In post test results the total 65% of teachers sustained good knowledge and 35% of them had moderate
  • 61. Chapter Two: Review of Literature 47 knowledge, which shows a significant improvement in their knowledge toward insect stings prevention and first aid. The study concluded that the teaching program for teachers regarding first aid was essential for improvement in their knowledge (Raju, 2016). 2.8. Section K (Literatures Regarding Attitude): Teacher must take the responsibility and must have the will to deal with school emergencies because he/she represents the first line in saving school children’s life during school time. Thus, this matter relates to attitudes which affects such wish or wills, this also includes teachers acceptance for child with special needs or chronic illnesses in their classes (Joseph et al., 2015; Vaz et al., 2015). Attitudes are well-defined as total evaluations toward some objects and issues or attitudes are emotion that habitually influenced by human beliefs, that predispose our responses to objects, persons and occasions. The relationship between attitudes and action is mutual in which both of them affecting each other. In brief term attitudes represents subjective evaluation of our beliefs, behaviors and concepts (Baumeister and Bushman, 2011; Feldman, 2011; Myers, 2014). There are three component of attitudes, believe (cognitive component), feeling (affective component) and behavior (Hewstone et al., 2005). Attitudes are usually abstracted into three classes of human response and they are: - Cognitive: represents our beliefs toward objects or other persons. - Affective: represents our feeling toward individuals or objects. - Behavioral: represents our actions toward objects and persons (Walker et al., 2007). Attitudes are formed due to numerous influences, and all of them considered as forms of learning. So that, attitude formed by direct contact,
  • 62. Chapter Two: Review of Literature 48 direct instructions, interaction with others and indirect conditioning (observational learning) (Ciccarelli and White, 2015). Chinese research conducted by Li et al., in 2012 for knowledge and attitude of preschools’ staff regarding pediatric first aid in Shanghai, China; and aimed to assess basic level of knowledge and total attitude about first aid among respondents. A cross-sectional study was performed among staff of selected preschools by using of stratified random sample. The tool of study was a multiple choice questionnaire. The research result revealed that none of 1067 study participants were answered all questions correctly and just 39 individual (3.7%) carried out successful scores. Particularly, insufficient knowledge about first aid for epileptic fits detected which only (16.5%) of them answered such questions correctly. While the correct answers for eye chemical injuries, inhaled poison, and choking respectively were 23%, 27%, and 30.1%. Attitude concerning first aid administration was positive in majority of participants, and most of them felt positively toward first aid learning and accepted the importance of learning such skills. Nutshell, these scores carried out using multiple linear regression and revealed that higher scores were associated with higher education and previous first aid training. Depending on result of study that showed low level of knowledge regarding first aid the study concluded that there was an urgent need to arrange practical educational sessions regarding first aid for preschools’ staff and undergraduate ones (Li et al., 2012).