Level of knowledge about basic life support of undergraduate students from the health area

Introduction: Basic Life Support (BLS) refers to the procedures that must be performed in situations of cardiorespiratory arrest or airway obstruction, and therefore, undergraduate students and health professionals must be highly trained to perform. Objective: To determine the level of knowledge about Basic Life Support (BLS) and the associated factors among undergraduate students from the health area in their last year of school in a public university. Methods: This is a cross-sectional study with undergraduate students in Physical Education, Nursing, Pharmacy, Medicine and Dentistry at the Universidade Estadual de Ponta Grossa, Brazil. Data collection was carried out in 2019, in the last month of course completion, by a trained researcher using a self-administered questionnaire containing sociodemographic data, professional training, perceived self-knowledge and a validated BLS instrument. There was an association between the outcome “undergraduate students’ knowledge” dichotomized as high (≥70% correct) or low level (<70% correct) and the independent variables (sociodemographic data, professional training and perceived self-knowledge) and the performance of the binary and multinomial logistic regression (p<0.05). Results: 191 undergraduate students participated in the study, being 85.6% of the chosen universe. A total of 30 participants (15.7%) had a high level of knowledge on BLS, being students from the Nursing (n = 12) and Medicine (n = 18) courses. While 35.3% of Nursing students and 46.2% of Medicine students had a high level of knowledge about BLS, there were no students from the Physical Education (0.0%), Pharmacy (0.0%) and Dentistry (0.0%) courses. In the crude analysis, the low level of knowledge was associated with younger age (OR=2.75, 95%CI:1.22-6.21), not feeling safe to perform BLS (OR=3.12, 95%CI:1.38-7.01) and the fact that the discipline was not part of the undergraduate course (OR=18.35, 95%CI:2.44138.1). In the adjusted analysis, the fact that the discipline was not part of the undergraduate course (OR=13.41, 95%CI:1.74-103.12) remained. Conclusion: Most students had a low level of knowledge about BLS, and only students from the Medicine and Nursing courses demonstrated a high level of knowledge. After adjustment, the fact that the discipline was not part of the undergraduate course was associated with a lower level of knowledge about BLS.


INTRODUCTION
Cardiovascular diseases represent the main cause of death worldwide: more people die annually from these diseases than from any other cause. It is estimated that 17.7 million people died from cardiovascular diseases in 2015, representing 31% of all deaths at global level 1 . Among the main causes of Cardiorespiratory Arrest (CRA) are acute myocardial infarction, coronary heart disease and cardiac arrhythmias. In Brazil, between 2004 and 2014, 8.8% of deaths were due to myocardial infarction, angina and other ischemic heart diseases 2 .
External causes, such as traffic accidents, stab wounds or firearm injuries and airway obstruction by foreign bodies are also factors that can lead to CRA. They represent the second leading cause of death in Brazil in general terms, and the most important cause in the age group ranging from 1 to 49 years 3 . In the country, it is estimated that in 2019 more than 140,000 deaths occurred due to external causes 4 .
Basic Life Support (BLS) refers to the procedures that healthcare professionals must perform on patients in situations of CRA or airway obstruction. Cardiopulmonary resuscitation (CPR) is at the core of the BLS and consists in the set of performed maneuvers aiming at artificially maintaining arterial flow to the brain and other vital organs, until the spontaneous circulation resumes 5 .
CPR success depends on theoretical knowledge and also on psychomotor skills by the professionals who perform it, such as using the automated external defibrillator (AED) or adopting actions to clear the airway, among other possible measures 6 . The time factor is a determining variable, considering that any delay in treatment can result in sequelae and have an impact on patient survival 7 . Therefore, the training of health professionals in immediate and standardized care for this clinical situation can have favorable prognostic implications 8 .
Undergraduate courses in the health area are beneficial environments for the training of human resources prepared to deal with BLS. However, studies have shown a low level of knowledge about BLS in analyses by students from specific courses, such as Medicine 9 or Nursing 10 , or in the comparative analysis between several courses in the health field 11,12 . The low level of knowledge has been associated mainly with the lack of prior BLS training among students 9,12 , and among professionals with little clinical experience 13,14 . Most of the studies have as their target-populations students from different periods 9,12,15 , interns 11 or professionals 13,14,16,17 , and little emphasis has been placed on the undergraduate students from different courses in the health area. In this context, the present study aimed to determine the level of knowledge about BLS and the associated factors in undergraduate students attending health courses in a public university.

Study universe
The study was carried out with undergraduate students from courses in the health area in 2019. The University has an yearly entry system for all evaluated courses, with the Medicine course ending in August and the remaining courses in December 2019.
The inclusion criteria for the study were: being able to complete the health course in 2019; and agree to sign the Free and Informed Consent Form (ICF). The exclusion criteria were: having some unfinished discipline that would prevent the student from completing the course in 2019; students who took a break from College or dropped out of the course; or did not accept to participate in the study.
The bachelor's degree in Physical Education course at UEPG started in 2010, and the first version of the Political-Pedagogical Project of the Course (PPC) is still used. The course lasts four years until course completion, with a minimum of 3,419 (three thousand, four hundred and nineteen) hours. The Nursing course at UEPG started in 2007. The fourth version of its PPC has been used since 2014, with five years until course completion, and a minimum of 4,800 (four thousand and eight hundred) hours. The bachelor's degree in Pharmacy at UEPG started in 1956, and the fifth version of its PPC has been used since 2005. The course lasts five years until course completion, with a minimum of 5,028 (five thousand and twenty-eight) hours. The Bachelor's Degree in Medicine at UEPG started in 2009. The PPC is in its second version and has been active since 2011. The course duration comprises a period of six years, with a minimum total of 8,258 (eight thousand, two hundred and fiftyeight) hours. The bachelor's degree in Dentistry at UEPG started in 1956 and the evaluated class was using the tenth version of the PPC, implemented in 2005. The PPC has a minimum total of 5,164 (five thousand one hundred and sixty-four) hours.

Variables
The study outcome was the undergraduate students' level of knowledge, dichotomized according to the number of correct answers in 14 (70%) of the 20 questions answered in the questionnaire: high (greater or equal than 70% of correct answers) or low (<70% of correct answers) level of knowledge about BLS. This cutoff was adopted considering the average grade for approval in the disciplines by the University. Although the calculation was based on the correct answers, we chose not to exclude the unanswered questions from the analysis and the latter were classified as 'not correct' .
The independent variables were divided as follows: • Sociodemographic variables: sex (woman and man) and age (up to 24 years and 25 years or older).
• Professional training: undergraduate course (Physical Education, Nursing, Pharmacy, Medicine and Dentistry) and training for BLS (no and yes).
• Course duration in hours: more than 40h (no and yes) or more than 100 hours (no and yes), offer of a specific discipline in BLS/emergencies during undergraduate school (no and yes), completion of the discipline (no and yes), modality of the offered discipline (optional or mandatory), discipline approach (theoretical and theoretical-practical/ practical) and believing that the offered discipline was sufficient (no and yes).
• Perceived self-knowledge: feeling confident (no/ some situations and yes) and believing in the need to take courses (no and yes).

Data analysis
The data obtained were stored in a Microsoft Office Excel spreadsheet, and subsequently analyzed using the Statistical

RESULTS
The study was carried out with 191 undergraduate students, totaling 85.6% of the chosen universe that met the eligibility criteria, with a proportion of participation per course of 37 undergraduate students from the Physical Education course (84.1%), 34 from Nursing (97.1%), 33 from Pharmacy (80.5%), 39 from Medicine (84.8%) and 48 from Dentistry (84.2%) ( Table 1). Chart 1 shows that the highest proportion of correct answers was 40% (11.5%) of the BLS questionnaire, followed by 35% and 65%, with 9.4% among the undergraduate participants.
Right answer % Wrong answer % Did not answer %

DISCUSSION
In the present study, the majority of the undergraduate students from the health area in the present study showed a   However, other studies have found a large proportion of incorrect answers in questions about the CPR sequence 11,19 . The difficulty in learning these subjects can be attributed to the lack of consistent and continuous study by the students.
In the crude analysis, age was an associated factor, where younger students had a lower level of knowledge about BLS.
Other studies with undergraduate students showed that students attending more advanced periods of the courses obtained a higher number of correct answers 12 , as well as in a study with lay people in Portugal, where older age was associated with a higher level of knowledge 20 . Another study, also carried out with lay people carried out in the state of Minas Gerais, Brazil, did not verify this association 21 , as it was not verified between doctors and nurses 17 . The difference in results may be associated with the difference in methodology and the target audience participating in the study. Although older age does not necessarily imply greater knowledge, it is possible to assume that older people have had more opportunities to go through learning experiences or the practical need for its application, that is, age would not be a direct predictor, but the greater clinical professional experience, in studies with students or professionals in the area, or greater maturity among older individuals to deal with adverse situations, in the case of studies with lay people.
The fact that the present study considers courses with different course completion periods -for instance, the physical education course is completed in four years, while the medical course is completed in six years -might have interfered with the results. Additionally, considering that entering an educational institution generally occurs later due to the competitive entrance exam, the medical course may include older students.
One must also consider the fact that Nursing students might have attended a technical course in the area. Based on these aspects, the results must be considered with care, as these variables are difficult to interpret. When the results were adjusted, there was no association with age in the final model.
In the crude analysis, another associated aspect was not feeling confident to perform the BLS and low knowledge.
Moreover, an information verified here that needs to be explored was a minority of the undergraduate students feeling confident or able to perform emergency procedures, which demonstrates a priority necessity of training for these future professionals.
A study with Nurses found a moderate positive correlation between the performance of BLS procedures and clinical experience 14 and a study with newly graduated physicians showed an association between longer time in clinical practice and greater confidence when performing CPR 13  area courses showed a greater impact on the level of knowledge than on the previously performed extracurricular courses.
This may be associated with the fact that the disciplines have a workload distributed throughout a continuous teachinglearning process, rather than an eventual one, such as training courses. Moreover, the offer of curricular disciplines with evaluation activities that follow the standard for learning assessment may be more effective for students, since this methodology is less frequent in training courses.
Despite the contributions present in the study, some limitations should be highlighted, such as the methodological variability in the studies present in the literature and, therefore, difficulties for comparability.
Different collection instruments were found to measure knowledge in BLS, which, although validated, were not the same 11,12,20 . Among these, the questionnaire by Tavares et al. 12 was selected because it has been validated in Portuguese, applied to a sample containing different courses and has a large number of questions. The use of a questionnaire from another Brazilian study 12 that achieved results that were similar to these presented here can reinforce the sensitivity of the questionnaire in measuring BLS and its reproducibility, even in samples from different locations, and thus, it seemed to be an adequate instrument to assess the knowledge.
However, the study indicated a cutoff for the high level, with 84% 22 , a parameter considered high, in which a limited number of participants managed to reach this proportion. Therefore, considering the average grade for approval at the institution, it was decided to reduce the cutoff to 70%, and the knowledge was considered appropriate.
Another aspect that must be clarified is the limitation of using a questionnaire to measure the level of knowledge in BLS. About the procedural content, an assessment at the cognitive level only, in the theoretical field, becomes a limited way to assess the problem. Another question to be considered in future studies is the measurement of the participation in extracurricular activities in the area of urgency/emergency, such as leagues, monitoring activities or continuing education projects in the area. This information could help to better understand the apprehended knowledge and promote greater interest in the topic according to the intended future specialty.
Moreover, the sample is another factor of difficult comparability. While some studies include only one health course as the study universe 9,10,15 , others considered several courses regardless of the semester or year 11,12,19 , while others carry out studies with health professionals that have already graduated 13,14,17 and even lay people 20,21 . The present study assessed undergraduate students only, aiming to reduce the memory bias and increase the reliability of measuring significant knowledge. In this sense, the data from the present study become a matter of concern, considering that before working in a specific area of each profession in the health field, undergraduate students need to understand that they are health professionals and, for this reason, they must be prepared to deal with emergency situations inside and outside health services.
Therefore, integrality and interdisciplinarity must be an ever increasing part of the training of human resources in health.
When verifying that knowledge about BLS was not absorbed by most undergraduate students, that is, when they should be ready for the work market, this result reinforces the need to include permanent BLS discipline in HEIs for all courses in the health area , and mainly including an adequate perspective for the common needs within each health professional's field of action, as well as review and refresher courses of knowledge for graduated professionals, since even though they have had the training, the lack of continuous applicability of the learned knowledge can over time reduce the ability to use the clinical procedures necessary in specific cases of BLS.