Assessment of KAP towards BLS among dental medicine interns in selected health colleges, addis ababa ethiopia

Addis Ababa University School of Graduate Studies School of Medicine Department of Emergency Medicine and Critical Care Assessment of KAP towards BLS among dental medicine interns in se

Addis Ababa University School of Graduate Studies

School of Medicine Department of Emergency Medicine and Critical Care

Assessment of KAP towards BLS among dental medicine interns in selected health colleges, Addis Ababa Ethiopia

A thesis submitted to school of graduate studies of Addis Ababa University, Department of Emergency Medicine and Critical Care in partial fulfillment of the requirements for degree of masters in Emergency medicine and critical care nursing

June 2017, Addis

APPROVED BY THE BOARD OF EXAMINERS

This thesis by Abubeker Hussen is accepted in its present form by the board of examiners as satisfying thesis requirement for the degree of Masters of Science in Emergency medicine and critical care nursing

Table of contents

Contents

Table of contents i

Acknowledgment i

Acronyms i

List of tables i

List of figures i

Abstract i

1 Introduction i

1.1 Background of the study i

1.2 Statement of the Problem i

1.3 Significance of the Study i

2 Literature Review i

2.1 BLS Knowledge i

2.2 Attitude towards BLS i

2.3 Practices towards BLS i

2.4 Conceptual framework i

3 Objectives i

3.1 General Objective i

3.2 Specific objectives i

4 Methods and Materials i

4.1 Study Setting i

4.2 Study design i

4.3 Source Population i

4.4 Study population i

4.5 Inclusion and exclusion Criteria i

4.5.1 Inclusion Criteria i

4.5.2 Exclusion Criteria i

4.6 Sample size determination i

4.8 Study Variables ii

4.8.1 Dependent Variables ii

4.8.2 Independent Variables ii

4.9 Data Collection and Quality Control procedures ii

4.10 Operational definition of terms ii

4.11 Data processing and analysis ii

4.12 Ethical consideration ii

4.13 Dissemination and utilization of results ii

5 Results ii

5.1 Introduction ii

5.2 Demographic characteristics of the study participants ii

5.3 Knowledge of Basic Life Support among the study participants ii

5.4 The study participant’s attitude towards Basic Life Support ii

5.5 The study participant’s practice regarding Basic Life Support ii

5.6 Association of knowledge with independent variables ii

5.7 Association of attitude of dental internes towards BLS with independent variables ii

6 Discussion ii

7: Conclusion, Recommendation and Limitations of the study ii

7.1: Conclusion and Recommendations ii

7.2: Limitations ii

References ii

Annex ii

Annex I Information Sheet ii

Annex II Consent sheet ii

Annex III: Questionnaire ii

Acknowledgment

I am extremely grateful to the efforts exerted by my colleagues who facilitated the successful completion of this research proposal I would also like to extend my deepest gratitude to my advisors; for their time, effort and valuable comments and directions they gave in the preparation of this thesis

I also thank AAU for the chance given to me to pursue my master’s study And I

am grateful for Atlas Health Science College and AAU School of Dental Medicine for letting me conduct my study in their premises

Acronyms

AED Automated External Defibrillator AHA American Heart Association BLS Basic Life Support

CPR Cardio Pulmonary Resuscitation EMS Emergency Medical Service

KAP Knowledge Attitude Practice MMV Mouth to Mouth Ventilation

SCA Sudden Cardiac Arrest

List of tables

Table 1: Name of the Dental Medicine School at which the dental interns attending…… …15 Table 2: Demographic characteristics of study participants in the study assessment of KAP regarding BLS among dental interns at selected health science colleges Addis Ababa Ethiopia,

2017……….16

Table 3: Knowledge of the study participants towards Basic Life Support in the study assessment of KAP regarding BLS among Dental internes at selected health science colleges Addis Ababa, Ethiopia 2017………17

Table 4: Opinions of participants towards Basic Life Support in the study of assessment of KAP regarding BLS among Dental internes at selected health science colleges Addis Ababa, Ethiopia 2017……….19

Table 5: Study participants practice of Basic Life Support in the study assessment of KAP regarding BLS among dental internes at selected health science colleges, Addis Ababa, Ethiopia 2017……… 20

Table 6: Bivariate and multivariate logistic regression analysis of Knowledge status and the independent Variables………21

Table 7: Bivariate and multivariate logistic regression analysis of Attitude and the independent Variables……….22

List of figures

Figure 1 Conceptual frame work for assessment of knowledge, attitude and practice among dental internes regarding BLS, developed from literatures 8 Figure 2 Study participants' BLS workshop attendance 17 Figure 3 Study participants’ attitude towards BLS 20

Abstract

Background of the study: Life-threatening emergencies can occur at anytime, anywhere and to

anyone Such emergencies are somewhat more likely to occur within the confined dental office due to the increased level of stress which is often present Basic life support (BLS) is the foundation for saving life following cardiac arrest Fundamental aspects of BLS include recognition of Sudden Cardiac Arrest (SCA) and activation of the emergency response system, early Cardiopulmonary Resuscitation (CPR), and rapid defibrillation with an Automated External Defibrillator (AED)

Objective of the study: To determine KAP of internes studying dental medicine towards BLS at

Atlas Health Science College and Addis Ababa University School of Dental Medicine, Addis Ababa, Ethiopia 2017

Methods and Materials: Institution based prospective study was conducted at selected health

science colleges in Addis Ababa, in titled ‘assessment of KAP among internes studying dental medicine towards BLS’ from January to June 2017 The study sample was selected using convenience non random sampling since the interns studying Dental Medicine at Atlas Health Science College and AAU School of Dental Medicine were limited in number Data analysis of the study was conducted using SPSS version 20; descriptive and analytical statistics were done

Results: Most of the participants 76 (66.7%) know the adult chest compression depth Whereas

57 (50%) of the participants have reported their reluctance to perform resuscitation It was found that sex of the dental interns is significantly associated with their knowledge regarding BLS; female study participants were likely to have 5 times more knowledge regarding BLS than their male counter parts with AOR= 5.3299, at 95% CI (2,373, 12,282) As well those dental internes with less than 5 years clinical experience are more likely to have positive attitude towards BLS; with AOR=0.157 at 95 CI (0.062,0.399)

Conclusion: Knowledge and Practice skills of BLS were found to be poor among the dental

internes in the study A significant portion of the study participants have shown negative attitude towards providing BLS An organized curriculum for BLS should be part of the dental medicine

Keywords: Basic life support; BLS Knowledge; BLS Attitude; BLS practice

1 Introduction

1.1 Background of the study

Life-threatening emergencies can occur at anytime, anywhere and to anyone Such emergencies are somewhat more likely to occur within the confined dental office due to the increased level of stress which is often present Effective management of an emergency in the dental office is ultimately the dentist’s responsibility The lack of training and inability to cope with medical emergencies can lead to tragic consequences and sometimes legal complications Therefore, health professionals including dentists must be well prepared to manage medical emergencies Hence, BLS is an important tool until a medical emergency can be treated (1)

Basic life support (BLS) is the foundation for saving life following cardiac arrest Fundamental aspects of BLS include recognition of sudden cardiac arrest (SCA) and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), and rapid defibrillation with an automated external defibrillator (AED) (2) Initial recognition and response to heart attack and stroke are also considered part of BLS BLS also includes supporting breathing, circulation and maintaining an airway without using any equipment other than a simple airway device or protective shield (3) The main purpose of BLS is to maintain adequate ventilation and circulation till resources can be obtained to reverse the underlying cause of arrest (4)

Knowledge of BLS and expertise in CPR techniques ensures the survival of the patient long enough till experienced medical help arrives and in most of the cases CPR by itself is sufficient for survival (5) Different factors may affect the quality of CPR; such as feedback, education and monitoring and it have been emphasized that these should be developed together in order to improve quality (6)

Medical emergencies can commonly occur on the dental chair but fortunately serious complications have not been associated (3, 4) It is the utmost duty of dental practitioners including specialists to sustain life until medical help arrives in order to reduce chances of mortality and morbidity (7, 8, 9)

The golden rule in managing any emergency is by rendering BLS, CPR by following the basic principles which include position, airway, breathing, circulation, and definitive therapy

In a study conducted in Belgaum city, India it was found that overall in all the years, syncope / faint was seen by 40.9% of the respondents, 37.1% with hypoglycemic attacks, allergic reactions

by 17.1%, epileptic attacks by 7.6%, asthmatic attacks by 4.5% and angina 0.9% The frequencies of the emergencies encountered were once or even more Knowledge of the presence

of drugs and equipment in the emergency drug kit and the confidence in regard to use them was low Medical emergencies training were undertaken by 42% respondents, but in varying degrees There was a desire for further medical emergencies training by majority of respondents (9)

An increasing proportion of the population is medically at risk According to the European resuscitation council, sudden cardiac arrest is a leading cause of death in Europe, affecting about

7, 00,000 individuals a year (29) Although a number of studies have been carried out which sought to ascertain the emergency drugs and equipment, the lack of training and inability to cope with medical emergencies can lead to tragic consequences and sometimes legal action (9) For this reason, as all the health professionals, dentists must be well prepared to attend to and collaborate with the medical emergencies (10)

Although necessary knowledge is given at undergraduate level; but to maintain and update knowledge about recent advances periodic BLS courses should be made mandatory (11)

Few studies have assessed how competent dentists consider themselves in managing medical emergencies, and very few studies to my knowledge have reported studies involving dental interns (19)

1.2 Statement of the Problem

As health care professionals, dental practitioners encounter life-threatening medical emergencies

A study by M P Müller et al (17) found that medical emergencies are not rare in dental practice,

as about two- third of dentists faced at least one emergency during the 12- month study period In this study period, 57% of the dentists reported up to 3 emergencies and 36% of the dentists reported up to 10 emergencies Vasovagal syncope was the most frequent emergency (1238 cases) As two cardiac arrests occurred, it is estimated that one sudden cardiac arrest occurs per

638, 960 patients in dental practice 42 severe life-threatening events were reported in all

1, 277, 920 treated patients 567 dentists (92%) took part in emergency training following graduation (23% participated once and 68% more than once) In the context of medical emergencies, provision of a competent BLS carries a potential impact on lives

About half of the patients visiting a dental office have one or the other chronic disease or condition Few diseases and their treatments lead to medical emergencies during dental care or dental treatments Although a number of studies were conducted to improvise the availability of emergency drugs and equipment, the lack of training and inability to cope with medical emergencies can lead to tragic consequences and sometimes legal action (20, 21, and 22) All emergencies may not be life-threatening but the ability of a dentist to manage them play a key role in minimizing morbidity and mortality

A study by Shrestha R et al (27) revealed that the participants had inadequate knowledge on BLS Although 52% of the participants answered ≥7 of the 15 questions, only 7.4% (n=9) of

them could answer 75% of the questions correctly Other studies also demonstrated inadequate CPR knowledge in health care professionals (18, 28, 29)

Studies on BLS have been rarely conducted among dental students This institution based prospective study will be carried out to assess the knowledge, attitude and practice towards BLS among dental interns in Addis Ababa city

1.3 Significance of the Study

In Ethiopia, no previous published studies have been found in any data base regarding the need

of BLS in a dental set up It is essential for all dentists, be it in public or private sector, to be equipped with the required knowledge, apparatus and drugs The aim of this study is to assess the awareness of dental interns about the possible risks of a medical emergency in dental care and assess their knowledge, attitude and practice regarding BLS

Even though previous studies all over the world have been conducted regarding the awareness of BLS among students, doctors, and nurses of medical, dental & nursing colleges and found to be very poor which needed improvement This study will try to assess the KAP among interns studying dental medicine at Selected Health Science College’s in Addis Ababa The study results would be of paramount importance to focusing for consideration in including BLS trainings while developing dental medicine curriculum

Cardiac arrest continues to be a major cause of premature death in much of the world today Although the epidemiology of cardiac arrest and other emergencies have been well studied in many developed countries, there are still no studies done on assessments of knowledge, attitude and practice on BLS among interns studying dental medicine in Ethiopia This study may provide baseline information for other researchers and health professionals who are interested on the same area Besides this might initiates responsible bodies to treat cardiac arrest patients in order to take action and further increment of awareness at dental health care provision centers and institutes providing dental health education about the importance of proper training on BLS

2 Literature Review

The life of an individual is influenced by various factors including the condition of health, education, occupation, and socioeconomic status Among the various factors, the condition of health influences the life of an individual to a greater extent There are various systemic conditions of health like myocardial infarction, congestive cardiac failure, and stroke which may cause even sudden death of an individual There are different ways by which the occurrence of death of an individual may be prevented They include the instructions given and medications prescribed by health professionals, diet, and physical exercises In addition to these ways, BLS in case of medical emergencies is most important BLS refers to maintaining an airway and supporting breathing and circulation without using any equipment (12)

The American Heart Association (AHA) resuscitation guidelines recommend that all under graduate students who are in contact with the patients should have regular resuscitation training

(12,14)

Each individual in a community should know the importance of BLS in saving lives and improving the quality of community health (13) Effective management of an emergency in the dental office is ultimately the dentist's responsibility The lack of training and inability to cope with medical emergencies can lead to tragic consequences and sometimes legal complications Therefore, health professionals including dentists must be well prepared to manage medical emergencies Hence, BLS is an important tool until a medical emergency can be treated (14)

Emergencies do occur in the dental office Minimal knowledge about these incidents leads to feelings of insecurity, dissatisfaction or limited appreciation of responsibility of dentists The inability to perform proper BLS in the dental office will be the ultimate consequence (14)

2.1 BLS Knowledge

Knowledge of BLS and practice of simple CPR techniques increase the chances of survival of the patient until experienced medical help arrives and, in most cases, is sufficient for survival in itself (15)

In a study conducted in Bangalore city, India the knowledge scores of interns were marked as poor, average, and good Which was found to be among 102 interns, 18 (17.6%) had poor knowledge, 64 (62.7%) had average knowledge, and 20 (19.6%) had good knowledge about BLS (16)

In a study conducted in Salem, Tamilnadu, India it was found that 31% of the responders did not know the abbreviation of BLS as Basic life support 59 % failed to insist on looking for safety as the first step in BLS 89% failed to insist on activating EMS immediately after confirming the unresponsiveness in an adult 74% did not know that the right location of chest compression was the mid chest 73% of the responders did not know that the correct location of chest compression

in an infant was one finger breadth just below the nipple line 83% of the responders did not know alternative techniques of resuscitation when mouth-to-mouth ventilation was not opted 84% of the responders failed to select mouth-to-mouth and nose technique as the rescue breathing for infants 67% did not know that the depth of chest compression in an adult was 1.5

to 2 inches 83% did not know that the depth of chest compression in a child was one-third to one-half the depth of the chest 35% did not know that the chest compression in an infant was one-third to one-half the depth of the chest Only 35% of the responders answered the rate of chest compression as 100/minute in adults and children CPR Only 15% of the responders had correctly answered that the compression ventilation ratio in a child and adult single rescuer CPR was 30:2 Only 26% knew that the ratio of compression ventilation in a new born was 3:1 60%

of the responders did not know that the abbreviation of AED was ‘automated external defibrillator’, and only 56% knew that the abbreviation of EMS was ‘Emergency Medical Service’ 84% did not know that the first step in helping a suspected foreign body obstruction victim is to confirm the severity of obstruction by talking to him Only 30% were aware about the right technique of foreign body removal from an infant (19)

In the same study only 13% knew about the role of the recovery position in a spontaneously breathing unresponsive victim 66% of the responders did not know the early signs of stroke and only 54% per cent knew how to recognize and help a patient with acute coronary syndrome (19)

Looking closely at the individual groups 83% of the medical students, 65% of the medical interns, 89% of the dental students, 93% of the dental interns, 99% of the homeopathy interns, 98.4% of the nursing students, 69% of pre- and para-clinical doctors, 59% of the practicing doctors, 83% of the dentists and 83% of the homeopathy doctors had scored less than 50% of the marks (18)

2.2 Attitude towards BLS

In a study conducted in India, the attitude of interns was classified as positive and negative respectively Of all the interns, 69 (67.6%) had a positive attitude towards BLS and 33 (32.4%) had a negative attitude towards BLS (16)

In the study conducted by Varma L et al.(25) only 50.5% of the dentists were confident in

managing any emergency condition at their dental offices, which was similar to the findings in a study done by Muller and Broadbent, whereas the remaining had an attitude of calling an

ambulance in case of emergency conditions (22)

2.3 Practices towards BLS

It is recommended that all medical students and staff, who are exposed to patients, must be

trained to offer basic life support (18)

In the study conducted by Varma L et al 87.2% of the practitioners had emergency kits at the

dental office to handle medical emergencies, but this was in contrast to the findings (8.9%) in a

study done by Gbotolorun et al (25, 26)

Gonzaga et al (10) found that theoretical information without practical training is not enough to assure CPR competence Practical assessment is difficult to be performed through a questionnaire Practical skills could not be assessed in the present study however; we focused on the cognitive levels of BLS

A study conducted to assess the preparedness of dental practitioners toward medical emergencies

patients, and availability of emergency drug kits at their dental office 94.02% of the total practitioners enquired about medical and drug history, but only 67.11% of them obtained filled Performa and about 83.06% recorded vital signs All the above findings were high when

compared to a similar study conducted by Kumarswami et al which was mainly due to increase

in the awareness regarding medical emergencies among dentists (25)

2.4 Conceptual framework

Figure 1 Conceptual frame work for assessment of knowledge, attitude and practice among dental internes regarding BLS, developed from literatures

Knowledge about BLS Attended BLS

Attitude about BLS

Practice about BLS

Clinical

experience

Age

3 Objectives

3.1 General Objective

 To determine KAP of internes studying dental medicine towards BLS in Atlas Health Science College and Addis Ababa University School of Dental Medicine Addis Ababa, Ethiopia, November to June 2017

3.2 Specific objectives

 To determine the Knowledge of interns studying dental medicine towards BLS

 To determine the associated factors with the attitude of interns studying dental medicine towards BLS

 To identify the level of practice among interns studying dental medicine towards BLS

4 Methods and Materials

4.1 Study Setting

A cross sectional prospective institution based study was conducted from November to June

2017 The study was conducted in Dental Medicine Schools found in Addis Ababa In 2017 a total of eight dental medicine institutes were present in the country, of which four were found in Addis, of the four dental medicine institutes one was governmental and the remaining three were private The schools are Atlas Health Science College, Addis Ababa University School of Dental Medicine, Africa Health Science College and Sante Health Science College Since the Study is conducted on dental medicine interns Africa and Sante Health Science Colleges weren’t included

in the study because they didn’t have dental medicine interns currently The study was conducted in AAU School of Dental Medicine and Atlas Health Science College Atlas Health Science College was established on the year 2005G.C having three departments Since then the college has graduated more than 80 dentists The college has 300 students for the year 2017 of which 100 of them are dental medicine internes AAU School of Dental Medicine has 20 dental medicine interns for the current 2016/2017 academic year AAU School of Dental Medicine has graduated its first dental physicians 22, on the year 2008 E.C

4.2 Study design

A cross sectional prospective institution based study was conducted from November to June

2017 to investigate the KAP of dental medicine interns towards BLS in selected Health Science Colleges in Addis Ababa

4.3 Source Population

The source populations for the study were students studying dental medicine at selected dental medicine institutes at Addis Ababa, Ethiopia

4.4 Study population

The study population for this study was dental medicine interns of the 2017 academic year at the selected Health Science Colleges, Addis Ababa

4.5 Inclusion and exclusion Criteria

4.5.1 Inclusion Criteria

- Dental medicine interns at Atlas Health Science College and AAU School of Dental Medicine

- Willingness to participate in the study

4.5.2 Exclusion Criteria

- Not being in the Colleges at the time of data collection

- Not being willing to participate in the study

4.6 Sample size determination

The sample size for this study was all interns studying dental medicine at Atlas Health Science College and AAU School of Dental Medicine Addis Ababa, Ethiopia Hence the number of dental medicine interns at the institutions was very few; the study sample included all the dental medicine interns at the institutions’

4.7 Sampling Technique

From the Schools record using convenient sampling technique all interns studying dental medicine at Atlas Health Science College and AAU School of Dental Medicine were included in the study hence the study population were limited in number

4.8 Study Variables

4.8.1 Dependent Variables

 KAP of dental internes towards BLS

4.8.2 Independent Variables

 Socio demographic characteristics

 Work experience/ clinical experience

 Previous BLS training

4.9 Data Collection and Quality Control procedures

A structured self-administered questionnaire was used to collect data The questionnaire was adapted from previous studies The questionnaire was prepared in English Training was given for the data collectors for 2 days prior to the pretest and for 1 day after the pretest The content of the training for the data collectors included how to collect data, general objective, relevance of the study, and confidentiality of information While conducting training to the data collectors the training was conducted in the form of discussion going through the structured questionnaire To assure the data qualities the principal investigator has checked all the collected data for completeness, consistency, and clarity during data management, storage, and analysis

The pre-test was conducted on study participants prior to the study on a total of 10% of the sample size at AAU School of Dental Medicine The pretest was conducted among the 5th year dental medicine students of AAU School of Dental Medicine The questionnaires passed through

a pre - test, to make sure it measured what it intended to measure After the pre-testing the questionnaire was checked for its clarity, simplicity, understandability and coherency Correction was made based on the feedback For confusing words and phrases, locally known and comparable terms were used

The study entitled assessment of KAP regarding BLS among dental interns at selected Health Science Colleges, Addis Ababa Ethiopia; the data collection was conducted from April 20 to May 10, 2017

4.10 Operational definition of terms

 Knowledge: Respondent who answers greater and equal to 50 % of the total knowledge

questions are classified as having sufficient knowledge, and who answers less than 50 % of

the total knowledge question are classified as having insufficient knowledge about BLS

 Attitude: It refers to correct response of interns of dental medicine students regarding to

BLS for selected emergencies to the structured attitude questionnaire adapted from other

studies by the investigator for this study

 Practice: It refers to academic application of knowledge and skills on CPR

 Basic life support: Maintaining air way, breathing and circulation for patients with cardiac

arrest and other emergencies without drug administration

4.11 Data processing and analysis

The raw data was checked for any inconsistencies, coding error, out of range, and missing values and appropriate corrections were made The analysis was done using SPSS version (20) Descriptive analyses of socio demographic information, knowledge, attitude and practice was carried out

Association between variables were tested with Chi Square Test, Bivariate logistic regression model was used to assess association of independent variables with the outcome variable and calculate the crude (COR) and adjusted odds ratios (AOR)

For knowledge assessment the participants who scored ≥ 50 % of the total questions correctly were classified as having sufficient knowledge whereas who scored < 50 % of the total questions were classified as having insufficient knowledge

4.12 Ethical consideration

Letter of ethical clearance was obtained from the ethical review committee of school of Medicine, Addis Ababa University and letter of permission from authorities of Atlas Health Science College and AAU School of Dental Medicine was obtained to conduct the study in the colleges’ premises A written informed consent was obtained prior to data collection from each study participants

Confidentiality was ensured as the names of the study participants were not included in the data collection as well in data analysis