Awareness of First Aid Management of Epistaxis in Children Among Parents in Arar, Saudi Arabia

Background: Epistaxis is a relatively common condition, particularly among children, necessitating that parents be well informed about its effective management. Objectives: This study aims to explore the current level of awareness among parents in the Arar region, Saudi Arabia, regarding the first aid management of epistaxis and to highlight the importance of education in empowering parents to handle such situations. Methods: A cross-sectional study was conducted using a survey distributed among the Arar population (aged >18 years) who had at least one child and were willing to participate. Data were collected between mid-July and the end of September 2023 using a self-administered questionnaire, which included a consent form, sociodemographic and background items, and epistaxis knowledge-related questions. Results: A total of 342 participants (27.8% males) completed the questionnaire. It was observed that 47.4% of the participants' children had experienced epistaxis. Only around half of them (n=84; 51.9%) had received first aid management for epistaxis, and only 40.4% of the parents correctly identified all the necessary steps for managing it through first aid. There was inadequate knowledge regarding the causes/risk factors and appropriate first aid techniques for epistaxis. Certain sociodemographic factors were significantly associated with better knowledge of first aid management of epistaxis, such as female gender (p = 0.003), older participants (p = 0.002), and a higher educational level (p = 0.001). Conclusion: The study found low awareness of first aid management of epistaxis among parents residing in Arar, Saudi Arabia. Factors related to the demographic characteristics of the study participants were associated with this level of knowledge. These findings emphasize the need to improve awareness about first aid management of epistaxis, particularly among younger individuals, males, and those with limited education. Effective interventions should be developed to enhance first aid training, considering the specific risk factors associated with epistaxis.


Introduction
Epistaxis (bleeding that arises from the nasal cavity) is a frequent occurrence in both ENT and accident/emergency departments globally and is one of the most prevalent emergencies [1].It affects approximately 10-12% of the general population, with about 10% necessitating specialized medical intervention [2].While epistaxis may arise from either anterior or posterior sources, nearly 90% of nasal bleeding cases can be attributed to Kiesselbach's plexus (also known as Little's area) located on the anterior portion of the nasal septum.Notably, many of these cases can be effectively managed in a home setting [3].The nasal cavity features abundant vascularity, supplied by branches from both internal and external carotid arteries [4].
The etiology of epistaxis remains elusive in the majority of cases and can be categorized into two main groups: local causes associated with the nose, paranasal sinuses, and the nasopharynx, as well as systemic causes such as hypertension, blood dyscrasias, and the usage of anticoagulant medications [5].Risk factors for epistaxis in children include nose picking, trauma, nasopharyngeal mass, bacterial nasal colonization, and allergic rhinitis, among others [6].While certain cases of epistaxis may require medical intervention and hospitalization, most such instances are typically self-limiting and without profound implications.These milder cases can often be managed successfully with simple first aid measures, such as applying digital compression with the child's head tilted forward to avoid blood trickling back into the throat, packing with a piece of cotton, or cold compresses applied to the nose [7].It is essential to have sufficient knowledge of appropriate first aid techniques to handle acute epistaxis without immediate access to hospital facilities, despite the high prevalence of this condition [2].
Recognizing the need for first aid management, parents must understand the steps involved in stopping the bleeding and providing comfort to their children.Recent studies have shown that while parents are generally aware of first aid measures for epistaxis, their knowledge and confidence in executing these measures remain suboptimal [8,9].In a cross-sectional study conducted at government primary healthcare centers in Al-Madinah Al-Munawwarah, a province in Saudi Arabia, findings revealed that only 27.9% of parents accurately responded when asked about the correct course of action to take for a case of epistaxis [10].Meanwhile, in other studies, parents were moderately knowledgeable about this issue [9,11].Furthermore, many pervasive myths still exist surrounding epistaxis first-aid measurements [12].These practices highlight the need for more accurate, evidence-based guidance.As no related studies were conducted in our region, Arar (Northern Borders area, Saudi Arabia), this study aims to explore the level of awareness among parents in our region concerning the first aid management of epistaxis.The results will underscore the importance of education in empowering parents to handle such situations.

Research design
This cross-sectional study was conducted in Arar, the capital of the Northern Borders region (with a population of about 373,577) and one of the 13 provinces in Saudi Arabia, which has been described in detail previously [13].

Inclusion criteria
The study included parents who (1) were residing in Arar and had at least one living child, (2) were aged 18 years or above, (3) could read and write in Arabic or English, and (4) were willing to participate in the study.

Exclusion criteria
The exclusion criteria included parents who were (1) residing outside Arar, Saudi Arabia, (2) aged less than 18 years, and (3) unwilling to participate in the study.

Sampling method and sample size calculation
A convenient sampling method was applied to recruit participants.The study was advertised through social media platforms, such as Facebook and Twitter.The minimum sample size for this study was calculated according to Swinscow as follows: n=z 2 p(1 -p)/d 2 , where n is the calculated sample size, z is the level of confidence according to the standard normal distribution (for a level of confidence of 95%, z = 1.96, p is the expected awareness of 27.9% based on Al-Johani et al. [10], 1 -p = 1 -0.279 = 0.721, and d is the maximum acceptable error (= 0.05).So, the calculated minimum sample size was: n=(1.96) 2 × 0.279 × 0.279/(0.05) 2 = 309.The sample was increased to 340 by adding 10% to compensate for the incomplete questionnaires and dropouts.

Data collection and the related tool
All data were collected from mid-July to the end of September 2023 using an electronic self-administered questionnaire, which included a consent form, the sociodemographic and background items (15 questions), and the Epistaxis Knowledge-related items (12 questions).Each correct answer is given a score of one, and the maximum score is 12.The designed Arabic version of the questionnaire was prepared by reviewing the relevant literature [8][9][10], and a panel of experts in emergency medicine, first aid, and public health ensured its content validity to measure what it is intended to measure.The experts provided feedback on the relevance and clarity of the questions, and any raised concerns have been made accordingly.All collected data were anonymized during subsequent analysis.

Statistical analysis
The data obtained from the online survey were recorded in an Excel spreadsheet (Microsoft Corporation, Redmond, Washington, United States), assigned appropriate codes, and subsequently subjected to statistical analysis using IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York).Descriptive statistics such as counts and percentages were used to summarize the information.Tables were employed to present the findings comprehensively.Moreover, the chi-square test was employed to examine associations between demographic variables and knowledge of first aid management of epistaxis, considering a p-value of less than 0.05 as an indicator of statistical significance.right to withdraw at any time.Participants' confidentiality and anonymity were protected.

Basic characteristics of the study population
A total of 342 participants completed the questionnaire.Over half of the participants were 18-25 years old (n=184; 53.8%).Most participants were females (n=247; 72.2%), with the vast majority being married (n=30; 88.0%).Regarding the education level, 76.3% (n=261) of the participants had a college degree.Regarding occupation, more than half of the participants (n=175; 51.2%) were employed (Table 1).Data are presented as frequencies (n) and percentages (%).

The epistaxis background information of participants
As illustrated in    Only 40.4% of the respondents correctly selected the step that should not be taken for first aid management of epistaxis: "leaning the head back."Regarding the duration of intervention for applying pressure on the nose, only 22.85% of respondents correctly stated the time of 10 minutes.Regarding what can help prevent epistaxis, 39.2% of the respondents correctly stated all the measures, including drinking plenty of water, using a humidifier, and avoiding picking the nose.About 95.2% of the respondents noted that one should see a doctor if their child (children) experienced frequent or severe epistaxis.Regarding the first step in managing epistaxis, more than half of the respondents (51.7%) selected the correct state: sitting upright and leaning forward.

Participants' awareness of first aid management of epistaxis
Regarding recurrent epistaxis, when asked about its common cause, 39.5% correctly identified trauma to the nose.Additionally, 41.7% of the respondents correctly identified anemia as the most severe complication of epistaxis.One hundred thirty-six of the respondents (39.7%) correctly stated using a humidifier, applying a saline nasal spray, and avoiding picking the nose as measures of preventing recurrent epistaxis.Regarding the timelines for action, 94.3% of the respondents correctly stated that if bleeding does not stop within 20 minutes of applying pressure, the patient must see a doctor.

TABLE 4: The association between age, gender, level of education, occupation, and knowledge of first aid management of epistaxis
The chi-square test was applied.Significance was set at p < 0.05.

Discussion
Nosebleeds, also known as epistaxis, are a common medical concern worldwide, and Saudi Arabia is no exception.In Saudi Arabia, epistaxis has been reported as a frequent complaint in emergency rooms and primary healthcare settings.However, despite its prevalence, epistaxis often receives inadequate attention, as it is often considered a minor ailment [14].This notion is problematic, as epistaxis can result in significant morbidity and may occasionally signify underlying medical conditions.Therefore, understanding the general awareness of epistaxis within our region and globally is imperative to improve public knowledge, prioritize comprehensive management strategies, and mitigate potential complications associated with this seemingly benign condition.
Our study aims to assess the awareness level concerning the first aid management of epistaxis among parents in Arar, Saudi Arabia.The participants for this study predominantly comprise young adults between the ages of 18 and 25, with a higher representation of females.Furthermore, the participants exhibit relatively advanced educational backgrounds and are primarily employed.According to the findings, only 47.4% of the participants' children reported prior experience with epistaxis, substantially lower than the 60% global prevalence rate of epistaxis in the general population.This suggests a possible underreporting due to self-treatment and the perception of nosebleeds as a trivial event not requiring medical care [15].
The findings revealed that 32.6% of the participants had received first aid training for epistaxis management, while about one-third (33.3%) learned through the Internet.These findings are similar to those from other studies conducted in Saudi Arabia (Table 5).The study by Alshehri et al. found that 67% of the study participants had experienced epistaxis, and 54% had received information about first aid for epistaxis in Alahssa, Saudi Arabia [16].In another study, Almutairi et al. found that 79.9% of the people had experienced epistaxis at least once in their lifetime in Al-Majmaah, Saudi Arabia [17].Based on our findings, there is a significant knowledge gap on common medical emergencies that should be addressed through public first aid education and public health initiatives.-Out of the teachers surveyed, 54% of the participants had received information regarding first aid to stop epistaxis.Additionally, 67% of teachers reported that their students had previously experienced epistaxis.About 15% of teachers stated that they would not attempt to stop the bleeding, while only 25% mentioned they would apply pressure on the cartilaginous part of the nose.However, a higher percentage (57%) correctly understood that tilting the head forward is the appropriate action to take.Currently, the overall knowledge about first aid for epistaxis was modest, with slightly more than half of the participants demonstrating adequate awareness.However, it is worth noting that with convenient sampling and possibly more educated parents responding, there is a high chance this number in the general population will be low.Most of the participants (39.5%) identified trauma to the nose as the common cause of epistaxis.Regarding first aid, less than half knew what they should not do if their children have experienced epistaxis: leaning the head back.The study noted substantial knowledge about the duration of intervention, preventive measures, and appropriate initial management, as well as the emergency responses for epistaxis and its recurrence.In agreement with our findings, other studies concluded similar results (Table 5).Also, the present findings agree with the meta-analysis done by Alkhalifah et al., in which they found that "the average awareness level of epistaxis and its management was approximately 63%, indicating a moderate level of awareness among Saudi residents".The researchers concluded that "gender, prior knowledge, and profession were significant factors that could influence the levels of awareness observed in their analysis" [27].

Study limitations
The significant limitation of this study was the employment of observational cross-sectional design, limiting the ability to establish cause-and-effect relationships and challenging to assess changes or trends.It also may not account for confounding variables or control for potential biases.Secondly, since the study utilized electronic questionnaires to collect data, it was challenging to discover insights or observe the behavior of respondents in their natural settings and the potential for recall bias, as participants may not accurately

-
The study revealed that 27% of parents indicated that the initial treatment for epistaxis involves applying pressure while tilting the head downwards.

---
About 85.5% of the teachers in the sample were female.-As for the awareness and knowledge about epistaxis and related interventions, one-third of the teachers were wellinformed.-The highest level of awareness was related to head posture and nose pressure.majority of the participants (75.7%) were female, indicating a gender imbalance among the respondents.-Medical students possess a satisfactory understanding of the first aid and management techniques for epistaxis.-Self-education emerged as the primary source of knowledge acquisition for the respondents regarding epistaxis first aid and management.Out of the participants, 81% had a previous experience of epistaxis.-The collective level of knowledge was found to be 64%.-A significant 52.2% of the participants held the belief that adjusting the position of their head could halt the bleeding.Concerning epistaxis and how to handle it, approximately two-thirds of the teachers were informed.Those who taught scientific subjects, those who had received education on the topic, and young male teachers exhibited higher levels of understanding.

Table 2 ,
more than half of the respondents (n=223; 65.2%) had more than one child.Regarding the epistaxis experience of participants' children, the majority of the respondents' children (n=180; 52.6%) had never experienced epistaxis.Only around half of the participants' children (n=84; 51.9%) had received first aid management for epistaxis.A total of 114 respondents, accounting for 33.3% of the total sample, obtained knowledge on first aid management for epistaxis via online sources.Most participants felt it was important to know how to manage epistaxis through first aid.About 111 participants (32.6%) had ever attended any first aid training, with seventy-six (68.7%) feeling confident in managing epistaxis through first aid.More than half (n=192; 56.0%) of the respondents indicated they have never encountered difficulties managing epistaxis through first aid.

TABLE 2 : Epistaxis background information of the participants Data
are presented as frequencies (n) and percentages (%).

Table 3
presents the study findings on participants' awareness of the first aid management of epistaxis.Regarding the potential causes of epistaxis, the respondents provided mixed responses.When asked about the most common cause, 39.5% correctly identified trauma to the nose, while the majority of the respondents (41.9%) mentioned high blood pressure, 11.9% mentioned allergies, and only 6.7% cited dry air.

TABLE 3 : Study participants' awareness of first aid management of epistaxis
Data are presented in frequencies (n) and percentages (%).

of first aid management of epistaxis
Out of 8 (55.0%), the study participants' mean knowledge score was 4.4 (SD: 2.8).-First aid information was most frequently reported from the media (37.6%).-Knowledge and attitudes about first aid were impacted by gender, education, and socioeconomic level.Around 30.9% of parents exhibited a high level of understanding, while the remaining 67.5% displayed a moderate level of knowledge.-Several factors were linked to the -A majority of participants showed insufficient understanding of proper first aid for epistaxis, as indicated by only 37.1% demonstrating adequate knowledge.Regarding demographics, women, healthcare professionals, and individuals who had experienced nosebleeds in the past exhibited a higher likelihood of having good knowledge than others.-The primary sources of knowledge cited were relatives, friends, and social media rather than healthcare providers.

TABLE 5 : Characteristics of studies in Saudi Arabia concerning assessment of awareness level of first aid management of epistaxis
PHCs: primary health centers, KAUH: King Abdul-Aziz University Hospital.