Basic Life Support a Necessary Inclusion in The Medical Curriculum. A Multi-University Cross-Sectional Study in Uganda

doi:10.21203/rs.3.rs-1005560/v1

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Research Article

Basic Life Support a Necessary Inclusion in The Medical Curriculum. A Multi-University Cross-Sectional Study in Uganda

https://doi.org/10.21203/rs.3.rs-1005560/v1

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Background: Uganda continues to depend on a health system without a well-defined emergency response system. This is in the face of the rising cases of out-of-hospital cardiac arrest contributed largely to the high incidence of road traffic accidents. Non-communicable diseases are also on the rise further increasing the incidence of cardiac arrest. Medical students are key players in the bid to strengthen the health system which warrants an assessment of their knowledge and attitude towards BLS inclusion in their study curricula.

Methods: A descriptive cross-sectional study was conducted in 2021 among undergraduate medical students across eight public and private universities in Uganda. An online-based questionnaire was developed using Google forms and distributed via identified WhatsApp groups. Chi-square or Fisher’s exact test and logistic regression were performed in STATA 15 to assess the association between knowledge of BLS and demographics. P<0.05 was considered statistically significant.

Results: Out of the total 354 entries obtained, 351 were analyzed after eligibility screening. Of these, (n=250, 71.2%) were male less than 25 years (n=273, 77.8%). Less than half (n=150, 42.7%) participants had undergone formal BLS training.

Less than a third of participants (n=103, 29.3%) had good knowledge (≥50%) with an overall score of 42.3±12.4%. Age (p=0.045), level of academic progress (p=0.001), and prior BLS training (p=0.033) were associated with good knowledge. Participants with prior training were more likely to have more BLS knowledge (aOR: 1.7, 95% CI: 1.1-2.7, p=0.009).

The majority (n=348, 99.1%) believed that BLS was necessary and would wish (n=343, 97.7%) to have it included in their curriculum.

Conclusion: Undergraduate medical students have poor BLS knowledge but understand its importance. Current curricula should be revised to accommodate both the theoretical and practical aspects of BLS provision to meet the priority needs of Uganda’s health system.

Educational Philosophy and Theory

Internal Medicine

Knowledge

Attitude

Basic Life Support

Medical student

Emergency response

Medical curriculum

The provision of Basic Life Support (BLS) involves the recognition of sudden cardiac arrest followed by the activation of an emergency response system, early cardiopulmonary resuscitation (CPR), and rapid defibrillation with an automated external defibrillator (1). This can be provided by a health professional or any other trained bystander. Cardiac arrest is an increasingly common life-threatening event that accounts for more than 7 million deaths globally(2). Common causes of cardiac arrest include cardiovascular diseases such as ischemic heart disease, cardiomyopathy, and valvular heart diseases among others accelerated by sedentary lifestyles, smoking, alcohol, and physical inactivity(3). Trauma is another major cause of cardiac arrest that cannot be over-emphasized especially in resource-limited countries where emergency response services are not well established.

Uganda loses more than 35,000 individuals to road traffic accidents each year, largely due to delays in the initiation of BLS and transportation of victims to health facilities(4, 5). Additionally, the lack of confidence in the provision of BLS contributed in part by lack of formal training and refresher courses, even in-hospital CPR is often delayed(6). Reports indicate that only 18.4% of patients who suffered from a cardiac arrest in Mulago hospital received CPR (7). The heavy patient load owed to the alarmingly low doctor-patient ratio in Uganda may be another important factor explaining this deficit in health performance(8). In the setting where there’s a paucity of trained bystanders, measures to bolster health professionals’ performance in the emergency care of patients must be taken meticulously. Students under training for health professional courses provide an ideal group that can be prepared to improve the health standards in the shortest time possible.

Regardless of the increasing numbers of universities and training institutions in Uganda, the level of trained bystanders in the country remains to be determined. To train willing volunteers into by-standers, trainers must be in place to do so and medical students are an ideal group that can be nurtured to provide this necessary service(9). Some Universities such as Makerere University incorporate some aspects of first aid-BLS training in particular course units but knowledge of the practicability and retention of the information obtained from such training is not well studied. Therefore, this study aimed to assess the knowledge and attitude towards BLS among undergraduate medical students in Uganda to inform on the feasibility of the current medical schools’ curricula and how these can be improved to suit the country’s health care needs.

Study design and area

This was a cross-sectional quantitative study that targeted undergraduate medical students across eight public and private universities in Uganda from April to May 2021. The public universities include; Makerere University, Mbarara University of Science and Technology, Gulu University, Busitema University, and Kabale University. The private universities involved were; Kampala International University, Islamic University in Uganda, and King Caesar International University.

Study population

Undergraduate medical students undertaking Bachelor of Medicine and Bachelor of Surgery (MBChB), and other related courses including Bachelor of Nursing, Bachelor of Dental Surgery, Bachelor of Pharmacy at any of the aforementioned universities.

Selection criteria

All undergraduate medical students aged 18 years and above, enrolled in one of the above universities and undertaking the above-mentioned courses were eligible to participate in this survey. Being purely an online study, respondents without internet access were excluded.

Sample size calculation

The sample size was calculated using Epi Info StatCalc for infinite population surveys. A 5% acceptable margin of error was considered; design effect of 1.0; cluster effect of 1.0, and a power of 80%, giving us an estimated sample size of 384 participants at a 95% confidence interval (95% CI). To cater for non-response associated with online surveys, 10% of the estimated sample size was added leading to a final sample size of 422 participants.

Sampling procedure and data collection

Uganda was in a partial lockdown at the time this study was conducted, with schools and higher institutions of learning using a blended physical and e-learning system to maximize social distancing. Because of this, we opted to use social media platforms such as WhatsApp Messenger® for enrolling eligible participants through contact persons identified at the different participating universities using a convenience sampling technique.

A questionnaire was developed using Part 3 of the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science guidelines(10). A link to the Google form was sent to the potential participants via the identified WhatsApp groups and data collated. Sensitive details such as names, email addresses, registration numbers were not collected to ensure anonymity.

Data Analysis

Data cleaning, coding, and marking were done using Microsoft Excel 2016 and exported to STATA® 15 for analysis. Demographic characteristics, knowledge, and attitude of the participants towards BLS were first summarized as frequencies and percentages for categorical variables, and means for numerical variables. Knowledge score was calculated by awarding a point for every correct response to questions with a maximum score of 18 points. They were then converted to percentages. Knowledge was graded into good (≥50%) or poor knowledge (<50%). Chi-square or Fisher’s exact test and binary logistic regression were performed to assess the association between knowledge on BLS and demographics. P<0.05 was considered statistically significant.

Characteristics of participants

A total of 354 entries were obtained out of which three were from ineligible courses and were excluded. Finally, 351 fully completed entries were cleaned and analyzed. Of the analyzed, (n=250, 71.2%) were males and aged 25 years or less (n=273, 77.8%). Most participants were undertaking MBChB (n=301, 85.8%) mostly at a public university (n=320, 91.2%). The distribution of participants in the different eligible universities in Uganda is shown in figure 1 Most of the participants were in clinical years of their training (n=246, 70.1%). Only 150(42.7%) of the participants had undertaken BLS training before the study. Table 1 summarizes the baseline characteristics of participants.

Table 1

Characteristics of participants
Variable	Frequency	Percentage
Age
≤25 years	273	77.8
>25 years	78	22.2
Sex
Female	101	28.8
Male	250	71.2
University ownership
Public University	320	91.2
Private University	31	8.8
Study program
MBChB	301	85.8
Others	50	14.3
Level of academic progress
Preclinical stage	105	29.9
Clinical stage	246	70.1
Prior BLS training
No	201	57.3
Yes	150	42.7

Knowledge Of Basic Life Support

Of the 351 participants, less than a third (n=103, 29.3%) had good knowledge regarding BLS (a score of >50%). The mean knowledge score of all participants was 42.3% (SD=12.4%). Participants above 25 years (46 vs 41.2), MBChB students (42.9 vs 38.4), Clinical students (43.6 vs 39.2), and those with prior BLS training (44.7 vs 40.4) had more mean scores compared to their counterparts.

At bivariate analysis, age (p=0.045), level of academic progress (p=0.001), and prior BLS training (p=0.033) were significantly associated with good BLS knowledge. There was no association of university ownership (p=0.650), sex (p=0.541), or study program (p=0.065) with BLS knowledge as shown in Table 2.

Table 2

Participants knowledge of BLS
Variable	BLS knowledge
Variable	Good, n (%)	Poor, n (%)	p-value	Mean score (SD)
Overall	103(29.3)	248(70.7)		42.3(12.4)
Age			0.045
>25 years	30(38.5)	48(61.5)		46.0(12.0)
≤25 years	73(26.7)	200(73.3)		41.2(12.4)
Sex			0.541
Female	32(31.7)	69(68.3)		42.5(12.6)
Male	71(28.4)	179(71.6)		42.2(12.4)
University ownership			0.650
Private Universities	8(25.8)	23(74.2)		41.8(10.2)
Public Universities	95(29.7)	225(70.3)		42.3(12.6)
Study program			0.065
MBChB	94(31.2)	207(68.8)		42.9(12.4)
Others	9(18.0)	41(82.0)		38.4(12.1)
Level of academic progress			0.001
Clinical stage	85(34.6)	161(65.4)		43.6(12.5)
Preclinical stage	18(17.1)	87(82.9)		39.2(11.7)
Prior BLS training			0.033
No	50(24.9)	151(75.1)		40.4(11.9)
Yes	53(35.3)	97(64.7)		44.7(12.7)

Participants who had prior BLS training were more likely to be knowledgeable about BLS compared to those who had never received any formal training (OR: 1.7, 95% CI: 1.1-2.7, p=0,018) as shown in Table 3.

Table 3

Multivariate logistic regression analysis of factors associated with BLS knowledge
Variables	Adjusted Odds Ratio (aOR)	95% CI	p-value
Age
≤25 years	Reference
>25 years	1.6	0.9-2.6	0.082
Sex
Male	Reference
Female	1.1	0.7-1.8	0.577
University Ownership
Public	Reference
Private	1.3	0.6-2.8	0.497
Study program
MBChB	Reference
Others	0.5	0.3-1.0	0.051
Level of academic progress
Pre-clinical stage	Reference
Clinical stage	1.3	0.8-2.1	0.299
Prior BLS training
No	Reference
Yes	1.7	1.1-2.7	0.018

Attitude Towards Basic Life Support

Overall, participants self-reported a good attitude towards BLS (figure 2). The majority of participants, either strongly agreed (n=307, 87.5%) or agreed (n=41, 11.7%) that BLS knowledge was a necessary skill; (n=313, 89.2%) felt like they would voluntarily perform BLS on any victim who needed it while (n=343, 97.7%) would wish to see BLS included within their study curriculum.

Cardiac arrest accounts for more than 7 million deaths globally(2). For every minute without CPR, survival from sudden cardiac arrest decreases from 10–7%. Performing bystander CPR can reduce this rate of deterioration to just 3–4% per minute (11). Any efforts to reduce mortality due to out-of-hospital cardiac arrest (OHCA) must focus on increasing the number of trained bystanders. This is, however, a challenge in developing countries given the nature of their volatile emergency care systems. In the current study, we found that the majority of students lacked knowledge regarding the provision of BLS despite recognizing its importance. Prior BLS training was a significant predictor of good knowledge.

Like in many other parts of the world, our study revealed poor BLS knowledge with a mean knowledge score of 42.3±12.4%. In a related study conducted in Saudi Arabia among medical students, and overall mean knowledge score of 32.7% was reported(12). However, in Ethiopia, Tsegaye et al., reported that the majority of their participants had good knowledge about CPR(13). The probable explanation for the difference in results of their study and ours is that whereas we recruited students in the preclinical and clinical years, participants in the Ethiopian study were all in clinical years. Therefore, it is possible that they got training in basic life support or rather participated in emergency response during their clinical rotations. This was also evidenced in our study by the differences in the mean knowledge scores between clinical and pre-clinical years. The lack of uniformity in curricula development in Ugandan Universities is yet another factor that could have influenced results in our study. In a study conducted in Tanzania enrolling qualified health professionals(6), up to 80% of the participants scored less than 50% in their written assessment which is almost similar to findings from our study even when ours assessed medical students. This emphasizes the role of curriculum development in determining the quality of medical professionals in the country. Although some universities in our study such as Makerere University have first aid-BLS-related course units in the preclinical years, lack of hands-on sessions during the preclinical years and refresher courses thereafter may have led to the observed gaps in knowledge. Participants undertaking MBChB had more knowledge scores compared to other courses in the current study which communicates a gap falsely created on grounds that doctors are the ones handling emergencies that need BLS skills.

The proportion of participants with formal BLS training was very low in our study as it has been reported in many other countries(6, 13–16). This training not only improves the BLS knowledge but is also associated with better practices among beneficiaries. This has been adopted by the developed countries as a way of reducing OHCA through upscaling the number of trained bystanders at any available opportunity(17–19). In a study assessing CPR knowledge and attitude among secondary school students in Norway, it was reported that up to 335(89%) of participants had been trained to perform CPR, mostly from schools and a few by organizations like the Red Cross(20). Although undertaking BLS training has been emphasized by many studies as an indicator of good knowledge, it may not be an accurate marker if it is not coupled with active recall and rehearsal. Recent data shows that 50% of skills learned after BLS training are lost in the subsequent two months (21) as it is true for clinical exposure alone is sufficient enough for one to know BLS without training. For individuals that do not practice resuscitation, refresher courses to improve knowledge retention is recommended(23–27).

Many training approaches have been assessed to determine the most efficient but the most common challenge for all has been difficulties in knowledge and skills retention(28–30). Among the studied, self-directed learning methods and traditional teaching methods have been reported to be effective at skilling trainees if well supported by refresher training to improve knowledge and skills retention(31). These can be incorporated into the current students' training curricula to impart the desired knowledge and skills to trainees. Intending to upscale the trained bystanders and the quality of emergency response in the country, medical students by virtue of their training and exposure are more suitable candidates to set a pace to achieve this milestone. Fortunately, the current studies as do many previous studies in other countries, show that medical students have an excellent attitude towards BLS and are more than willing to take on BLS training. Since they are more likely to have opportunities for practicing the acquired skill sets, an important aspect in knowledge retention, the frequency of required refresher trainings would be lower increasing the feasibility of this approach.

To the best of our knowledge, this is the first study to assess the knowledge and attitude of BLS among undergraduate medical students in Uganda. Findings from this study suggest the need to strengthen the current curriculum, teaching medical students both the theoretical and practical aspects of BLS. Information from this study, though focused on medical students, may also be used to revise curricula in other faculties as a way of increasing the prevalence of trained bystanders in the country.

Being an online study conducted in the middle of the COVID-19 pandemic, data collection was only possible via online methods. Therefore, potential participants who did not have supporting gadgets, poor connectivity to the internet, or those who could not afford data costs for participating in this study were excluded. This might have led to selection bias which may limit the generalization of our study findings. Additionally, since the questionnaire was self-administered, there was a possibility of obtaining correct answers without a full understanding of the questions, recall bias and participants may have interpreted the questions differently.

We found that majority of undergraduate students in Uganda lack BLS knowledge and prior training was the most important factor significantly associated with better BLS knowledge. Regardless of this, participants had an excellent attitude towards BLS training and wished to have it integrated into their curriculum. Current curricula should be revised to accommodate both theoretical and practical aspects of basic life support. Further studies should be conducted to determine the feasibility of integrating BLS in non-medical curricula. This would increase the number of trained providers available to initiate CPR in the community.

aOR

Adjusted Odds Ratio

BLS

Basic Life Support

CPR

Cardiopulmonary Resuscitation

MBChB

Bachelor of Medicine and Bachelor of Surgery

OHCA

Out-of-hospital cardiac arrest

Ethical approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki; approved by the Mulago Hospital Research and Ethics Committee under reference number MHREC 2051. Informed consent was obtained from all participants and the study was anonymous.

Consent for Publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interest

The authors declare that they have no competing conflicts

Funding

This study was not funded.

Authors' contributions

NS conceptualized the idea. NS, GW, AI, and PM developed the study tools. NS, GW, AI, PM, AMK, GN, NKW, WZ, LK, JK jointly participated in the data collection process. NS, AI and GW prepared the first draft of the manuscript. AMK, JK, TSL, and AT provided extensive comments on the first draft and contributed to developing the final draft. All authors reviewed the final draft and approved the final manuscript.

Acknowledgment

The authors would like to appreciate Prof. Sarah Kiguli the PI of the Health-Professional Education Partnership Initiative (HEPI) for leading a way in developing undergraduate research in Uganda through mentorship and financial support. We commend the following students for assisting us in data collection: Victor Niwamanyire, Faridah Ainembabazi, Hilda Koriang, Patricia Kulwenza, Khushi Dhawan, Annet Karungi, Reagan Kakande, Patience Philomena Idro Anzoa, Misba Noori, and Melody Mercy Arindagye. In the same spirit, we appreciate all medical students in Uganda who spared their time to participate in this study amidst all the current challenges.

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No competing interests reported.

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Basic Life Support a Necessary Inclusion in The Medical Curriculum. A Multi-University Cross-Sectional Study in Uganda

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Abstract

Figures

Background

Methods

Results

Characteristics of participants

Knowledge Of Basic Life Support

Attitude Towards Basic Life Support

Discussion

Limitations

Conclusion

List Of Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1