Abstract
Burns are serious injuries, resulting in high morbidity and healthcare costs. Effective first aid improves outcomes. The aim of this study was to assess the knowledge and practice of first aid for burn injuries among medical and non-medical students in Saudi Arabia. A cross-sectional study (N = 408) was conducted, in which a questionnaire was administered assessing students’ experience with burns, as well as their hypothetical responses to vignettes involving patients with burn injuries. Although most students reported having personal experience with burns, and had received some information regarding burn first aid, only about half were able to provide correct responses regarding first aid techniques, and medical students were no more accurate than non-medical students in their responses. Results suggest that members of the Saudi Arabian population may lack appropriate knowledge about burn first aid, and education and public information resources may help to remedy this problem.
Burns are the fourth most prevalent form of trauma worldwide, and are one of the most devastating traumatic conditions confronted in practice, affecting the physical and the psychological state of patients at all ages. 1 In 2004, the incidence of burn injuries was approximately 11 million, affecting more patients than tuberculosis and HIV combined. 2 Burn injuries result in 180,000 deaths each year, with majority of these deaths reported in developing countries. 3 In the United States, the prevalence of burn injury in adults younger than 20 years is estimated to be 15 cases per 10,000 annually, with the majority affecting children younger than six and occurring at home. 4 Similarly, multiple studies indicate that children account for approximately half of the cases of burn injury in Europe. 5
Compounding their prevalence, burns are also one of the most costly types of injury to treat, largely because they often require long-term hospitalization and long outpatient recovery periods. 6 In the US, the cost of burn has been found to be significantly higher than for other medical problems, with primary care costs estimated at between $3000 to $5000 per day. 7 While daily costs for burn care are lower in low and middle income countries, they remain high in comparison to other medical costs.7,8 Consequently, prevention and early treatment of burns are especially important in order to improve patient outcomes, conserve medical resources, and reduce the cost of care. Promoting knowledge of the correct first aid procedures for treating burns is one potentially important way of addressing these goals.
The current recommendations published by the American Burn Association for administering first aid treatment to patients with burns include (1) cooling the burn with running water for at least 5 minutes (avoiding the use of cold water or ice), (2) removal of articles worn around the burnt area such as jewelry, watches, rings and clothes, and (3) administering ibuprofen or another pain reliever to reduce discomfort. 9 Other expert guidelines differ in some specifics. For example, the Australian and New Zealand Burn Association recommends that water should be applied to the burn for at least 20 minutes. 10 Experimental studies suggest that the optimal approach for cooling burn wounds is to use running water at a temperature between 12° and 18° C, whereas the use of ice is associated with an increase in tissue damage.11,12 Another experimental study supported the use of a longer period of treatment with water, finding significantly faster physiological improvement in burns initially cooled for 20 minutes, in comparison with those treated for 5 and 10 minutes. 13
Receiving appropriate first aid has been found to be particularly important in improving the chances of positive outcomes in patients with burn injuries. Quick and effective first aid after burn injury may reduce the extent of tissue damage, the risk of hospital admission, and total healthcare costs, particularly in developing countries with limited medical resources.14,15 In Vietnam, a case series of childhood burns showed that immediate first aid by cooling and further treatment such as subsequent skin grafting helped to prevent the progression of superficial burns to deep burns. 16 Unfortunately, survey research has indicated that knowledge of appropriate first aid procedures for burn injuries is poor in both developed and developing countries.17,18 Even among health care professionals, a number of studies have found knowledge of basic burn first aid to be lacking. For example, hospital workers in the UK reported poor general knowledge of adequate first aid in burn injuries. 19 However, education has been shown to be effective in this area, with participants in first aid courses demonstrating better knowledge of the procedures for treating burns when compared with the public in general. 20
Research regarding burn-related first aid knowledge in Saudi Arabia indicates findings largely similar to those in other societies. Among the general population, Kattan et al. reported that only 42.7% of Saudis were well-informed about how to deal with burns. 21 In a sample of Saudi pediatric health care professionals, Alomar et al. found that only 41% were aware of the use of water to treat burn wounds and only 3% were able to correctly identify the appropriate duration of water use. 22
The purpose of the present study was to determine and compare the level of knowledge and practice of first aid for burn injuries among medical and non-medical students in Saudi Arabia. Although previous research has addressed some elements of the general Saudi population, as well as certain groups of Saudi caregiving professionals, burn-related first aid knowledge among the Saudi student population has not yet been extensively studied. However, Saudi Arabia experiences a high prevalence of burn injuries, in part due to environmental conditions, and since many students likely to go on to serve professional caregiving roles it is especially important to understand the extent of burn-related knowledge in this population. Hence, it is hoped that the present study will stimulate further research at a larger level and will encourage policy makers to issue guidelines aimed at improving care for burn injuries.
Materials and Methods
The sample for this cross-sectional study included a convenience sample of 408 second- and third-year students (188 men, 220 women) at the Academic University in Riyadh, Saudi Arabia. The sample consisted of two subsamples: students enrolled in the College of Medicine (n = 206) and students enrolled in non-medical colleges (n = 202). After obtaining the participant's informed consent, an anonymous, self-administered online survey was sent to medical and non-medical students via email by the student affairs department. The participation was voluntary and the confidentiality of the participants was ensured and maintained throughout the study. Data collection took place between December 1, 2016 and February 28, 2017. Ethical approval was obtained from the Institutional Review Board.
Measures
Participants completed a self-administered structured questionnaire regarding knowledge of burn-related first aid procedures. The questionnaire was developed after an extensive review of the literature to assess the student’s knowledge of first aid for burn injury. To ensure content and face validity, two family physicians familiar with survey development assessed the questionnaire for appropriateness, accuracy and relevance. A pilot test performed on 10 medical students to assess the clarity of the questionnaire and the time needed to complete it, thereby contributing to the face validity of the questionnaire.
Demographics
Participant demographics collected included age, gender, college and the year of college.
Knowledge and Experience
A series of two questions were included to assess whether or not the participants had received any information previously about the first aid for burns and, if they had, what the source of the information was. Another series of two questions assessed if any of them had previous experience with burn injury and if they applied first aid at that time or not.
Burn Injury Vignettes
Knowledge about application of first aid for burn-related injuries was assessed using a series of three vignettes describing hypothetical scenarios involving burn injuries, with multiple response options for the correct method of administering first aid. Vignette 1 involved a situation in which boiling water was accidentally dropped on a child’s chest, with response options: “remove the child’s shirt and place the injured area under running water for 15 minutes,” “leave the shirt on, and ask for help,” “immediately pour water over the child’s body.” Vignette 2 involved a situation in which a man’s shirt catches fire on a camping trip, with response options: “look for water to pour over the injured area,” “ask the man to stop, drop, and roll,” “ask the man to remove clothing and place ice cubes over the injured area.” Vignette 3 involved a scenario in which scalding water was accidentally poured over a woman’s hand, with response options: “place ice cubes over the injury area,” “place the injured area under cool water for 10 minutes,” and “cover the area with a clean cloth and ask for help.” All vignettes also included the response option “don’t know.”
Analyses
Descriptive statistics, including frequency distribution and percentages were applied to both demographic data and responses to the questions. The chi-square test and other inferential tests were used as indicated. A p-value of less than 0.05 was considered statistically significant for all analyses. All analyses were conducted in SPSS 21.
Results
Descriptive statistics for participant demographics are presented in Table 1. A total of 408 participants (aged 18–25 years, mean age 20.96) completed the study, including 206 medical students and 202 students enrolled in non-medical colleges. The full sample included 220 women (53.9%) and 188 men (46.1%). In terms of living arrangements, 92.9% of the participants were living with their families.
Participant Demographics.
Table 2 summarizes the exposure to instruction about burn first aid that participants reported having received. A majority of both medical and non-medical students had been exposed to information from at least one source. The most common sources of information were school curriculum and the internet.
Reported Exposure to Burn-Related First Aid Instruction.
Note: Percentages for any exposure are within the total sample; percentages for specific sources are within the subset of participants with any exposure.
Regarding previous personal experience with burn injuries, 252 (61.8%) students reported having experienced a burn injury personally or in a close family member. Of these, 137 (54.4%) reported that they administered or received first aid for a burn. Treatments reported included 112 (81.8%) who had applied water to injured area, 99 (72.3%) who removed clothing or accessories from the area of injury, and 71 (51.8%) who used ice to cool burn injury area. Among those who applied water, 65 (58%) applied water for was less than 5 minutes, 37 (33%) for 05 to 10 minutes, 05 (4.5%) for 10 to 15 minutes and 05 (4.5%) for more than 15 minutes.
Participants’ responses to the first aid vignettes are summarized in Table 3. There were significant differences between medical and non-medical students in responses to Vignette 1, boiling water on a child’s chest (χ2 = 7.843, p = 0.049). Medical students were more likely than non-medical students to say that they did not know what to do in this situation (24.8% vs. 14.9%; χ2 = 7.84, p = 0.04) and somewhat less likely to give either incorrect response: to leave the child’s shirt on (6.8% vs. 10.9%; χ2 = 7.84, p = 0.04) or to immediately pour water over the child’s body (12.6% vs. 15.8%; χ2 =7.84, p = 0.04). The two groups also differed significantly with respect to their responses to Vignette 2, a man’s shirt on fire (χ2 = 10.037, p = 0.018), with medical students appearing to be more likely to select the correct response (tell the man to stop, drop, and roll). There was no significant difference between groups with respect to their responses to Vignette 3, a woman with a scalded hand (χ2 = 6.449, p = 0.092), with a small majority of both groups selecting the appropriate response (apply cool water for 10 minutes).
Responses to Burn Injury First Aid Vignettes by Medical or Non-Medical Student.
A further analysis found that there were significant differences in the knowledge between those who received information about first aid of burns (67.8%) and those who did not receive information (32.2%) in responses to Vignette 1 (boiling water on a child’s chest), chi-square = 9.332, p = 0.025. Participants who received information about first aid of burns were more likely than those who did not receive information to say that they did not know what to do in this situation (11.3% vs. 8.6%), and more likely to give either correct response: to remove the child’s shirt and place the injured area under running water for 15 min (42% vs. 15%) or to immediately pour water over the child’s body (8.8% vs. 5.4%). The two groups also differed significantly with respect to their responses to Vignette 3 (a woman with a scalded hand), chi-square = 8.369, p = 0.039, where participants who received information about first aid of burns were more likely to select the appropriate response (apply cool water for 10 minutes) (39.3% vs 14.3%). However, there was no significant difference between the two groups with respect to their responses to Vignette 2 (a man’s shirt on fire), chi-square = 3.028, p = 0.387, with participants who received information about first aid of burns appearing to be more likely to select the correct response (tell the man to stop, drop, and roll).
A further comparison of the knowledge of first aids in burn injury showed no statistically significant differences on the three vignettes describing hypothetical scenarios between participants who have had burn injury in their family members (62.4%) and participants have not had burn injury in their family members (37.6%) (p = 0.11, p = 0.21, p = 0.07) respectively.
Discussion
Burn injuries are a serious form of trauma, having high morbidity and healthcare costs. In this context, knowledge and awareness about first aid for burns has great potential for reducing negative health outcomes, as well as economic costs, for patients. Applying the appropriate and recommended first aid treatments for burns has been found to have a favorable impact in terms of reduction in pain, length of hospitalization and the need of skin grafting or admission to ICU.12,23 Most guidelines recommend applying cool (but not cold) water for a period of between 5 and 20 minutes. 24 Several studies have found a lack of widespread knowledge of burn first aid among both members of the general population and among professional healthcare providers, in both the developed and developing world.16–19 For example, Harvey et al. conducted a study including 7,320 inhabitants of New South Wales to determine the current level of knowledge of first aid for burn injuries, reporting that while the majority of the participants proceeded to apply cold water on burns area, only 9% of them would do so for 20 minutes. 25 In Kwa-Zulu Natal, South Africa, 47% of 277 burn victims had not received any first aid after the injury. 26 Similarly, a study conducted on undergraduate medical students in the UK reported poor knowledge of burns first aid. 19
Reflecting this general trend, the results of this study indicated that 61.8% of this sample of Saudi university students had previously been exposed to burn injury themselves or in their family members; however, many of them did not administer any first aid after the burns. This suggests that the outcomes may have been poor in these cases, and may have been substantively improved by the application of simple first aid techniques. Furthermore, the majority of those who did use the correct first aid technique of applying water on burn area did not do so for the recommended duration, with only 5 out of 112 students reporting having applied water for more than 15 minutes. The students in this study also demonstrated limited knowledge of correct first aid techniques, with only about half of the sample selecting the appropriate response to each of the three hypothetical burn scenarios with which they were presented.
Thus, it appears that the majority of students had inadequate knowledge of current recommendations for burn first aid, which is to remove any clothing or other materials in contact with the affected area and apply cool water to the burn for at least 20 minutes according to several studies and the Australian and New Zealand Burn Association. It is also worrisome that many of the students indicated that they would apply ice as a first aid technique for burns, since this is not only contrary to professional recommendations, but also has been found to be linked with the potential for greater damage to the injured tissue.10,13 Surprisingly, the findings of this study showed that there was no statistically significant difference between medical and non-medical students in terms of their knowledge of first aid for burns. This is probably because the second-year medical students had not yet been exposed to the medical curriculum for burn first aid. However, it is particularly worrisome that these medical students demonstrated poor knowledge of first aid for burns, given their position as future healthcare professionals, and the high prevalence of burn injuries in Saudi Arabia.
This study has a number of limitations related to the sample design and measures used. The use of a convenience sample from a single location means that the results of this study cannot necessarily be generalized to the population of all Saudi Arabian university students. The sampling strategy may also have resulted in response bias, with students who were more interested in the subject of burn first aid being more likely to participate, which may imply that even the relatively low level of burn first aid knowledge exhibited in this sample may be an overestimate of the population more generally. Additionally, the use of a multiple-choice format to assess burn first aid knowledge is also likely to produce an overestimate of the extent of knowledge, since some participants will have responded correctly by chance, while others may be able to identify the correct answer when presented would not necessarily be able to produce it without prompting in a real first aid scenario. Further research on a larger scale and employing more diverse methods is called for in order to address these shortcomings.
Conclusion
The results of this study suggest that the knowledge level of first aid for burn injuries among both medical and non-medical students in Saudi Arabia is seriously limited, with particularly poor knowledge of the optimal duration to apply water to burn injuries. Among medical students, this issue could potentially be addressed by providing burn first aid instruction at an earlier point in the medical college curriculum. More broadly, since a lack of information appears to be a significant barrier to implementation of correct first aid procedures, promotion of a public information campaign regarding this topic may be particularly useful in improving knowledge and practice among both university students and the general population. Since proper first aid can have a substantial impact in reducing the health impacts and healthcare costs associated with burns, this has the potential to be a relatively inexpensive method of influencing these important outcomes. For example, these results may be taken to suggest that the subject of first aid for burns should be introduced to students while they are in high school and added to curriculum of first year in the university curriculum. We hope that this study will serve to encourage education authorities to consider strategies such as establishing mandatory general first aid courses, including for burn-related injuries, among these groups.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
