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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234On-line version ISSN 1980-220X

Rev. esc. enferm. USP vol.49 no.4 São Paulo July/Aug. 2015

http://dx.doi.org/10.1590/S0080-623420150000400015 

Original Article

Knowledge of the Portuguese population on Basic Life Support and availability to attend training

Conocimiento de la población portuguesa acerca del Soporte Básico de Vida y disponibilidad para realizar formación

Maria dos Anjos Coelho Rodrigues Dixe 1  

José Carlos Rodrigues Gomes 1  

1Instituto Politécnico de Leiria, Escola Superior de Saúde de Leiria, Unidade de Investigação em Saúde, Leiria, Portugal

ABSTRACT

OBJECTIVE

To evaluate the level of knowledge and the availability of the Portuguese population to attend training in Basic Life Support (BLS) and identify factors related to their level of knowledge about BLS.

METHOD

Observational study including 1,700 people who responded to a questionnaire containing data on demography, profession, training, interest in training and knowledge about BLS.

RESULTS

Among 754 men and 943 women, only 17.8% (303) attended a course on BLS, but 95.6% expressed willingness to carry out the training. On average, they did not show good levels of knowledge on basic life support (correct answers in 25.9 ± 11.5 of the 64 indicators). Male, older respondents who had the training and those who performed BLS gave more correct answers, on average (p<0.01).

CONCLUSION

The skill levels of the Portuguese population are low, but people are available for training, hence it is important to develop training courses and practice to improve their knowledge.

Key words: Cardiopulmonary Resuscitation; First Aid; Knowledge; Health Education

RESUMEN

OBJETIVO

Evaluar el nivel de conocimiento y la disponibilidad de la población portuguesa para llevar a cabo la formación sobre Soporte Básico de Vida (SBV) e identificar algunos factores relacionados con su nivel de conocimiento acerca del SBV.

MÉTODO

Estudio observacional realizado con 1.700 personas que respondieron a un cuestionario compuesto de datos sociodemográficos y profesionales, formación, interés en la formación y conocimientos sobre SBV.

RESULTADOS

De los 754 hombres y 943 mujeres, solo el 17,8% (303) asistió a un curso sobre SBV, pero el 95,6% manifestó disponibilidad para realizar la formación. En promedio, no presentaron buenos niveles de conocimientos en soporte básico de vida (contestaron bien 25,9 ± 11,5 de los 64 indicadores). Los respondedores mayores, del sexo masculino, los que llevaron a cabo la formación y los que ya prestaron SBV contestaron bien, en promedio, más cuestiones (p<0,01).

CONCLUSIÓN

Los niveles de conocimiento de la población portuguesa son bajos, pero las personas están disponibles para la formación, por lo que es importante desarrollar cursos de formación y entrenamiento a fin de mejorar sus conocimientos.

Palabras-clave: Resucitación Cardiopulmonar; Primeros Auxilios; Conocimiento; Educación en Salud

Introduction

A medical emergency is the health sector activity comprising all the events happening from where an emergency situation takes place, until the moment of its conclusion with restoration of an adequate health level(1). In Portugal, those involved in the emergency medical integrated system are: the public, the emergency center operators (emergency number 112), the technicians of the emergency patients guidance center (CODU - Centro de Orientação de Doentes Urgentes), law enforcement officers, firefighters, ambulance crews, emergency ambulance technicians, doctors and nurses, technical and hospital staff, telecommunications and informatics technical staff(1).

Saving lives involves a sequence of steps that constitute the chain of survival, with four steps, namely: early access to integrated medical emergency; early initiation of basic life support (BLS); early defibrillation and advanced life support (ALS)(1).

The BLS under citizen responsibility(1) is a well-defined set of procedures with standardized methodologies and the following objectives: recognize life threatening situations; know when and how to ask for help; have the ability to start immediately and without aid of any equipment, maneuvers to preserve oxygenation and circulation until the arrival of specific teams and eventually, the restoration of normal cardiac and respiratory function(1).

The prevalence of accidents in Portugal has caused victims at home, at work and on public spaces, being a current health problem that reflects the way of life and the organization of spaces and society. In 2011, there were 32,541 road accidents in Portugal resulting in 42,851 casualties. The fatalities (30 day-period) amounted to 891(3).

Ischemic heart disease is the leading cause of death worldwide. In Europe and the US, ischemic heart disease is the leading cause of sudden cardiac arrest(1). About a third of victims of acute myocardial infarction die before reaching the hospital, most within an hour of the symptoms onset. Data from various European countries show the annual incidence of cardiac arrest in the prehospital system is almost 40 per 100,000(1).

Sudden cardiac arrest is about 11% of deaths per year in Germany(4). In this and other emergencies, a rapid intervention would save people and prevent complications. About 50 to 65% of cardiac arrests occur at home. In such cases, family members who are close have the power to intervene. Many of these people would be saved if they were rescued in the first 3-4 minutes after the critical event(1-2,4). Given this fact, many authors stress the importance of including first aid training in school curricula(5).

To provide proper care, people need sufficient and adequate knowledge on BLS, which sometimes does not happen, requiring training(8) either in person or online(10). If the latter is of quality(12), it can favor the increased number of trained people by reducing the need to travel to attend courses.

Given the above and the potential value of first aid training as a strategic element to reduce mortality and morbidity caused by accidents and emergencies(11), this study aimed to: assess the knowledge level on BLS of the Portuguese population; know their willingness to carry out training in BLS and identify some factors (age, gender, frequency to a BLS course and previous experience in BLS) related to the level of knowledge about BLS.

Method

We conducted an observational descriptive and correlated study. The population comprised Portuguese residents in continental Portugal, the Azores and Madeira islands, aged 18 years or over, able to read and write and who where working in public and private institutions. The selection of data collection sites and sample was conducted as follows:

  1. We made a list of all public and private institutions to which we had access in the yellow pages;

  2. Two public or private institutions in each city of Portugal, including the islands of Azores and Madeira were selected by lot;

  3. The study protocol and its respective applications for authorization were submitted to the board of directors and ethics committee of the chosen institutions;

  4. After authorizations were granted, the employees of each institution in charge of instruments application were defined. They were sent instructions for data collection;

  5. The instruments were applied to respondents in a room chosen for this purpose, before the start or in the end of the work activity.

  6. After filling out the questionnaires, respondents put them in a ballet box in the room to maintain anonymity;

  7. The employees returned the completed questionnaires to researchers by mail.

  8. The non-probabilistic sample consisted of 1,700 respondents of both genders (55.6% women and 44.4% men), mean age of 37.7 years (SD = 10.5), who exercised functions in 250 of the 318 institutions selected (participation rate of 78.6%).

The applied instrument contained three parts, described below:

Sociodemographic and professional data: residence; age; gender; marital status; educational level and profession.

Training and interest in BLS training: frequency to any BLS course; experience in performing BLS; any citizen can help a victim in life-threatening situation: who should have knowledge about BLS; opinion about beginning BLS training in a teaching program; BLS training in the workplace; BLS training in associations; BLS training providers; interest in receiving BLS training; willingness to undertake BLS training and previous experience of volunteering or in health institutions.

BLS knowledge: 64 affirmations based on orientation defined in national and international guidelines for this article(1-2,13). The correct answers received the score 1, and wrong answers received the score 0 (zero). Thus, the total score ranged from 0-64 points. For content validation, the instrument was appreciated by field experts (doctors and nurses), and a pretest was applied to 20 people with the same characteristics of the target population. There was no need to make changes.

The study protocol was approved by all the ethics committees of the institutions. In institutions where there was no ethics committee (180 institutions), the protocol was approved by their administration boards. Before the application of instruments, the study objectives and purposes were explained for all the subjects. Before completing, all participants signed the informed consent form.

The SPSS (Statistical Package for the Social Sciences), version 17, and descriptive and inferential statistics were used. Since the variable of level of knowledge about basic life support presented normal distribution (Kolmogorov-Smirnov), we used the Pearson correlation and the t Student test, establishing a significance level of 95% with p<0.05.

Results

Sociodemographic and professional characteristics of the sample

More than half of the respondents were female (55.6%), married (60.7%) with mean age of 37.7 ± 10.5 years. The education of the majority (65.1%) was until 12th grade or higher education, and 30.2% of respondents were administrative staff or similar (Table 1).

Table 1 Distribution of the sample answers regarding sociodemographic and professional characteristics - Portugal, 2010-2012. 

Variables %
Gender (n = 1,697) Male 754 44.4
Female 943 55.6
Marital status (n=1,690) Married 1025 60.7
Divorced 190 11.2
Single 461 27.3
Widowed 14 0.8
Educational level(n= 1,690) Incomplete primary 13 0.8
Complete primary 175 10.4
6th grade 112 6.6
9th grade 289 17.1
12th grade 572 33.8
Higher education 529 31.3
Profession (1,644) Members of the armed forces 6 0.4
Senior management of public administration 20 1.2
Specialist in intellectual and scientific professions 380 23.1
Technicians and intermediate level professionals 214 13.0
Administrative staff and alike 497 30.2
Services and sales personel 171 10.4
Agricultural and fishery skilled workers 18 1.1
Factory workers, craft and related trades workers 69 4.2
Plant and machine operators 40 2.4
Unskilled worker 113 6.9
Student, working student 83 5.0
Retired 15 0.9
Unemployed 15 0.9
Military 3 0.2

Training and experience of the Portuguese population in basic life support

Only 303 (17.8%) had attended a BLS course, the majority in the Portuguese Red Cross (23.5%) or qualified training centers (21.8%); 14.6% needed to perform BLS, with traffic accident (22.5%) as the most cited situation. The intervention carried out more times (47.5%) was calling 112 (Table 2).

Table 2 Distribution of the sample answers in relation to training and experience in BLS - Portugal, 2010-2012. 

According to 54.1% of the participants, any citizen can help a victim and, therefore, must have knowledge on BLS (81.4%). They also indicated that training should be done in the workplace (84.9%). The National Institute of Medical Emergency (63.6%) and the Firefighters (62.1%) were the most cited to conduct training in BLS (Table 3).

Table 3 Distribution of the sample answers regarding the opinion about who should attend BLS training and where - Portugal, 2010-2012. 

Who should attend BLS training and where? Yes No
% %
Any citizen can help a victim in life-threatening situation 857 54.1 728 45.9
All citizens should have knowledge on BLS 1,320 81.4 301 18.6
Teachers should have knowledge on BLS 249 15.4 1,372 84.6
Firefighters should have knowledge on BLS 461 28.4 1,160 71.6
Health professionals should have knowledge on BLS 436 26.9 1,185 73.1
In addition to the aforementioned, others should have knowledge on BLS 79 4.9 1,542 95.1
The military should have knowledge on BLS 263 16.2 1,358 83.8
Police should have knowledge on BLS 297 18.4 1,317 81.6
BLS training should be done in the workplace 1,436 84.9 256 15.1
BLS training should be done in cultural and recreational associations, aimed at community groups 1,446 88.4 189 11.6
BLS training should be given by the National Institute of Medical Emergency 1,048 63.6 599 36.4
BLS training should be given by the Ministry of Health 823 50.0 824 50.0
BLS training should be given by the Portuguese Resuscitation Council 187 11.4 1,459 88.6
BLS training should be given by the Red Cross 814 49.4 834 50.6
BLS training should be given by the Firefighters 1,024 62.1 624 37.9
BLS training should be given by the Civil Protection 578 35.1 1,068 64.9
BLS training should be given by Schools 783 47.5 866 52.5

Among the respondents, 522 (30.9%) emphasized that training in BLS should be initiated in the 2nd grade; 482 (29.8%) in the 1st grade, 502 (28.6%) in the 3rd grade, 155 (9.8%) in secondary school, and 13 (0.8%) mentioned it should be integrated into higher education (0.4%), with equal percentage mentioning that BLS training is not necessary (0.4%). Regarding availability to attend a training, 655 (38.6%) said they had plenty of availability, 378 (22.2%) said they were available, 592 (34.8%) reported being a bit available, and 75 (4.4%) have not expressed any availability.

Knowledge of the population about basic life support

Before a breathing victim, more than 90% of respondents would ask someone to call 112 (Portuguese Medical Emergency number). More than half of respondents gave correct answers for several indicators, among which: before approaching a victim, one should evaluate the security situation (79.9%); in a situation of electrocution, the rescuer must ensure that the power source was turned off before approaching the victim (79.6%); ensure there are safe conditions for approaching the victim (79%); try to see, hear and feel if the victim breathes for 10 seconds (77.9%).

Table 4 Distribution of the sample answers about knowledge on BLS - Portugal, 2010-2012. 

Among the 64 indicators, participants have given correct answers for 25.9 ± 11.5 on average, which is less than half of the proposed indicators. The level of knowledge on BLS (r=0.98; p <0.01) increased as the respondents' age increased. On average, male participants who already had the training and those who had performed BLS hit more questions than female participants who did not have the training nor have performed BLS (p<001), as shown in Table 5.

Table 5 Results of the Student t test application regarding the knowledge level* of the sample on BLS - gender, frequency of some BLS course and performance of BLS - Portugal, 2010-2012. 

Variables N Average of correct answers Standard deviation t P
Gender Male 754 27.3 12.0 4.521 0.000
Female 943 24.8 11.0
Have you attended any BLS course Yes 303 35.6 10.7 17.481 0.000
No 1,398 23.8 10.6
Have you ever had to perform BLS Yes 243 31.0 11.5 7.627 0.000
No 1,425 25.0 11.3

*values may range between 0 and 64.

Discussion

More than half of the study sample was female (55.6%), a percentage similar to the Portuguese population(14). According to the 2011 census(15), about 47% of the population is married. Data in this study are different, with a greater number of married subjects (60.7%). However, data include 13% of individuals living in common-law marriage, which is different from information in the 2011 census.

According to the census, 15 %(14)of people have higher education, which is much lower than the percentage observed in this study (31.3%). Approximately 30.2% of the sample have a profession in the area of administrative personnel and alike, and this value is explained by the selected data collection sites (companies and schools). In the general population,trade, hotels, transports and communications, and other service activities, are the professional activities where more people are employed, approximately 30% and 29%, respectively(14).

The results of several studies show that the implementation of basic life support measures by the citizen/lay people with training reduces mortality and morbidity rates(7,15-16). Individuals who had cardiopulmonary resuscitation (CPR) of a trained citizen/lay person are four times more likely to survive for 30 days that those in which CPR was not applied(17).

In the present study, the low percentage (17.8%) of people who attended a BLS course is noteworthy. In this regard, several studies have mixed results: in some, the vast majority of spectators of critical events did not have first aid training(7), in others, on the other hand, more than half of the sample (54.1%) had CPR training, and 21.2% immediately initiated CPR(19). In another study(11), the authors found that 77.9% of participants had attended some kind of preparation in the area of first aid, although 61% had not done any training in the past five years(20).

Among the most frequently cited training locations are the qualified training centers (21.8%) and the Portuguese Red Cross (23.5%), different from data found in other studies(16,20-22). In a study conducted through telephone interviews with 7,320 respondents, the most common sources of training in first aid, more specifically in burns, were books (41.7%) and the internet (32.9%). In only 9.8% of cases the respondents resorted to the health authorities and surgery doctors as sources of information/training(23). On the other hand, in a study in Brazil, the authors(16) found that 35.6% had their training in the drivers' preparation course and 20.6% had it in the workplace. These differences may be due to the type of sample, place and type of data collection instrument.

Of the 1,668 people participating in the study, 1,425 (85.4%) never had to perform BLS. Traffic accident was the most reported situation (22.5%) for those who had already provided assistance, a slightly higher data (12.2%) than that found in another study(16).

Citizens have taken several measures in an emergency situation, such as: application of a bandage/dressing(18), positioning the victim(11), bleeding control(11), ensure safety at accident site(10), release of the victim(16), opening the airway(11), precautions against hypothermia(16), cardiopulmonary resuscitation(16)and providing tranquility to the victim(11).

Taking into account the probability of avoiding 4.5% of potential prehospital deaths with immediate BLS(24), and considering the first link in the chain of survival(1), in this study, 47.5% of participants asked for help by immediately accessing the emergency medical system (dial 112), which is in agreement (31%) with results from another study(16).

When asked about who should offer the training, 63.6% mentioned the National Institute of Medical Emergency. Training is carried out by doctors and nurses in this institution, which is in line with the highlighted information in the literature, stating that it should be done by skilled personnel(7,10,16).

Approximately 95.6% of the sample showed availability to attend the training, and similar results (94.45%) were found in the study carried out with students(25). Training must be offered in cultural associations aimed at community groups (88.4%) or in the workplace (84.9%). These options would facilitate adherence to training by avoiding the displacement of participants.

Training in BLS should begin in the student population and before the start of higher education(6). Authors of recent studies(4) showed that even nine-year-old children can perform CPR if properly prepared. Having the training is important and there should be recycling to improve knowledge and confidence of those involved(4).

In a quasi-experimental study of students with average age of 21.5 ± 0.74 years who received formal training and practice in first aid, the authors(25) found these students had better knowledge than those who had not attended training (p <0.001). Similar results were found by other authors(8) in a study with Danish students (average age of 17.5±1.2 years) and students from 13 European countries(26). Some studies have shown that even individuals who had training presented low values of knowledge(25) and some said they did not feel prepared(16). Still, it is proven that adult training in BLS is effective and necessary(28), reinforcing the need for recycling and updating knowledge(7).

Regarding the level of knowledge, as in another study(7), it was found that the studied population had insufficient and some incorrect knowledge. Male respondents who attended a course in BLS and those with experience in BLS showed higher levels of knowledge on BLS, on average. In a study with students, the authors(25) found that women and those who had previous training showed higher level of knowledge on BLS. The rate of correct answers in 64 questions was 25.9%, higher than the 10% found in another study(16). However, the content and the questions are not similar with those of the present study (degree of difficulty/different scope).

According to international guidelines(1-2,13), more than 50% gave wrong answers for the questions related to chest compressions. However, 79.9% of respondents gave correct answers on the items concerning the safety of rescuer.

When the victim breathes and if not traumatized, 51.4% gave right answer for the question of the proper placement, a higher value than that from another study(14). The victim should be placed in the recovery position to prevent airway obstruction and consequent respiratory arrest(1).

When the victim chokes, only 33% of respondents said the Heimlich maneuver should be performed. Such maneuver should be performed whenever there is serious airway obstruction and the victim is conscious. If choking is mild and the cough is effective, coughing should be encouraged and the person monitored. However, if the person is unconscious and the obstruction is severe, the rescuer should call 112 and begin CPR(1).

The area of interventions to the child had the lowest percentage of correct answers, between 22.5% (faced with the unconscious child, perform CPR for a minute before calling help) and 11.8% (in an infant in cardiac arrest, five chest compressions should be alternated with two breaths). In infants, chest compressions must follow the compression-ventilation ratio of 15: 2 (with two rescuers)(1).

Conclusion

The results of this study reinforce the need for training laypeople in BLS to reduce mortality and morbidity rates in situations of accident and sudden illness in extra-hospital setting. Although there are several courses in the Portuguese community, both in the classroom and online, some mandatory, it is necessary to introduce the subject in the school curricula of all young people as early as possible. Theoretical and practical training programs should be conducted in schools and workplaces to empower the population in this area, reducing morbidity and mortality due to accidents and emergencies.

Respondents had low levels of knowledge on BLS, evidencing the need and the availability to have the training. Courses should be managed by health professionals, including nurses, maximizing the skills of these professionals in BLS. Despite some difficulties in completing the instrument given its extent, respondents found it useful to realize the knowledge gaps and the importance of attending the training.

We encourage replication of the study in other research scenarios, particularly with children and teachers. In future studies, it would be important to increase the sample size and develop longitudinal studies, after conducting theoretical and practical training, aiming to assess their effectiveness. It would also be interesting to develop documentary analysis to verify the morbidity and mortality of victims of accident or sudden illness rescued or not by lay people with and without training.

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Received: June 24, 2014; Accepted: May 13, 2015

Corresponding author: Maria dos Anjos Coelho Rodrigues Dixe. Escola Superior de Saúde de Leiria, Campus 2, Morro do Lena, Alto do Vieiro, Apartado 4137, 2411-901 - Leiria - Portugal. maria.dixe@ipleiria.pt

Autor correspondente: Maria dos Anjos Coelho Rodrigues Dixe. Escola Superior de Saúde de Leiria, Campus 2, Morro do Lena, Alto do Vieiro, Apartado 4137, 2411-901 - Leiria - Portugal. maria.dixe@ipleiria.pt

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