Choking or acute airway obstruction is the emergency condition which is usually first dealt by general public and only then by health professionals. It has been documented in literature that educating the public about choking hazards and its management can positively affect the incidence of choking events and mortality [1].

Choking is defined as "a foreign object that is stuck in the pharynx (back of the throat) or trachea (windpipe) that causes a blockage of, or muscular spasm in the airway. If there is mild airway obstruction, the child should be able to clear it, but if it is complete, he or she will be unable to speak, cough or breathe. Unless there is intervention at this point the casualty will become unconscious and could die. Choking is characterized by the sudden onset of respiratory distress associated with coughing or gagging, or stridor (loud, harsh, high pitched respiratory sound). Similar signs and symptoms may also be associated with other causes of airway obstruction, such as laryngitis, or epiglottitis, which require different management [2].

Choking that cause serious unintentional injuries occurring in the childhood are the leading cause of death among children of age group 1 to 19 years, representing nearly 40% of all deaths in this age group. Each year, an estimated 8.7million children and teens from birth to age 19 years are treated in the emergency departments (EDs) for unintentional injuries and more than 9,000 die as a result of their injuries-one every hour [3]. Choking is hazardous for all ages. It is the fourth leading cause of unintentional injury or deaths, followed by poisonings, motor vehicle crashes and falls [4].

Etiology of choking varies according to the age group and different preventive and management strategies are required for different age groups to tackle this problem. Public should be educated about the problem of choking through mass media. Parents, child care givers, School personals must be trained so that a healthy child does not lose their life because of easily preventable causes. Education and awareness remains the most important weapon in preventing this fatal event [5, 6, 7].

Choking is preventable; it could be reduced by identifying risk factors and implementing strategies to manage the risk factors accordingly. One of the most important risk factors for FBA is a lack of knowledge by the caregivers. Strategies for choking prevention include education the prevention and the first aid for chocking [8, 9, 10].

Preschool age is a famous stage of life. This group accounts for 11.5% of the Iraqi population. Nursery school is the safest place to providing care to these children in absence of mothers. On the other hand, pre-schoolers are at risk of infection, injury and other health risks in nursery schools because of their high mobility, interest, lacking of knowledge and adverse environmental situations [11].

First aid instructions provide information and skill to give secure awareness and practices to improve children safety in nursery schools [12]. The role of nurses personally or through their professional associations is to give their attention for providing supportive requirements and preventive measures for nursery school children.

Choking occurs among children when foreign bodies like foods or small objects block the airway and prevents oxygen from getting to the lungs and the brain. Brain damage or even death may occur if brain remains without oxygen for more than four minutes. Many children die from choking each year [4]. Hence, emergency management training efforts, which are complementary to a formal EMS system, need to be considered. These approaches typically build on existing care being provided by first responders, by the community, and by family members. Studies have identified successful models to train, equip, and optimize the performance of village volunteers, police, and commercial drivers for first aid of injured persons [13].

This current study aimed to

• To assess the level of preschool children’s knowledge and reported practices regarding prevention and first aid maneuver of chocking.
• To evaluate the effect of supportive strategies regarding prevention and first aid maneuver of chocking among preschool children.

1. There will be significant difference between pre- and post- supportive strategies of preschool children’s knowledge and reported practices scores regarding prevention and first aid maneuver of chocking.
2. There will be a significant association between preschool children’s’ knowledge and their reported practices.

Research design

Quasi experimental research design (pretest-posttest) was adopted and utilized to accept or reject research hypothesis.

Sample and sample size

In this study, a stratified sample of 200 preschool children aged older than 4 years old was recruited to test the effect of supportive strategies regarding prevention and first aid maneuver of chocking. Preschool children were selected from the nursery school. Sample size was calculated by using power analysis was conducted using 0.05 as the level of significance, 0.95 as the power and effect size of 0.25. The required sample size with children older than 4 years old.

Setting

The study was conducted at four governmental nursery schools in Al Kut city/Iraq. Ten percent of these nursery schools were selected randomly which constitute four nursry schools. Four nursery schools from governmental was selected randomly. The nurseries were Al - Kut Kids , Al -Yasamin, Al -Yanabeea & Al- Worood nursry. Two hundred preschool children were selected randomly from four nursery , 50 children from each nursery school

Instruments

Three tools of data collection:

Structured interview sheets were developed by the researchers after reviewing of related literatures included the following items:

1. Socio-demographic characteristics for preschool children include: gender, age...etc.
2. Socio-demographic characteristics for parents of preschool children include: gender, age, occupation,etc.

Tool II and Tool III adopted from American Heart Association Guidelines, American Red Cross, the European Resuscitation Council, Consensus on Science with Treatment Recommendations , 2015)

Preschool Children’s’ knowledge about chocking, which include: definition of chocking, causes, types, clinical manifestation, first aid and prevention, Source of child’ knowledge about chocking and previous experience chocking for him. It was containing 6 questions (yes=2 or No=1) with total score of 12 for children’s’ knowledge. A score <50% was considered unsatisfactory, while score 50-70% were considered fair and scores >70% were considered good.

Part I: Preschool children’s’ reported practice regarding prevention of chocking, which include checklist about measurers used in prevention of chocking, 4 items that child should know to prevent chocking.
Part II: Children’ reported practice regarding first aid for chocking child, checklist include standardized steps for first aid used in reliving of chocking for children older than one year, contain 5 items answers of items were in form of yes(score=2) and no(score=1). The scoring system of check list was 10 marks, scores <65% were considered unsatisfactory and scores 65-75% were fair and score >75%considered satisfactory.
Part III: (Supportive strategies for prevention and first aid maneuver of chocking) This is the last part which included a guide booklet for preschool children and their parents about prevention and first aid of chocking. This booklet had been developed by the researchers after reviewing the related literature. The booklet included colored pictures about the causes and first aid for chocking.

Pilot study

A pilot study was carried out on 10% of sample size (20 preschool children) to ensure the clarity, applicability of the tools, test feasibility of the study and estimate sample size and the time needed for data collection. The result of pilot study confirmed that the study was feasible. The sample of the pilot study was included in the total sample size.

Validity and reliability

Tools were submitted to a panel of five experts in different fields of pediatric nursing to examine the content validity (covering, clarity, wording, length, format and overall appearance) and its equal 93%. Reliability test was done using Cronbach’s test to be accepted reliability on (Cronbach alpha was 0.82).

Ethical consideration

An approval was obtained from the ethical committee of nursing faculty. An official permission was taken from the Kut Directorate, and the directors of the selected nursery schools. The parent partner (mother or father of preschool child) gave informed written consent prior to participation of their child. The participation was voluntary and confidentiality of data was ensured. Also take the assent from preschool child and told him and his parent that they has the right to withdraw from the study without any explanation.

Procedure

The study was carried out on three phases

1. Preparatory phase: A review of current and past, national, and international related literature in the various aspects of the problems using books, articles, periodicals, and magazines was done. This phase ended with a pilot study.
2. Planning phase: Based on the findings of the exploratory phase, the supportive strategy was developed, after an extensive literature review considering children their levels of understanding. After that, the training was conducted.
3. Implementation phase:

Administrative & Ethical consideration

• Prior to data collection and conducting the study, an official permission was taken from the Kut Directorate. The preschool children and one of their parent gave informed written consent prior to their participation in the study. Participation was voluntary and confidentiality of data was ensured. A clear explanation was given to them about nature, aim, and expected outcomes of the current study.
• At the initial interview, the researcher introduced herself to initiate a line of communication, explain the nature and purpose of the supportive strategies. The study was carried out in the morning from 9 Am to 2 Pm; children’s’ knowledge was assessed using (Tool II) while their reported practices were assessed by using an observation checklist (Tool III).
• Developing a training session Based on obtaining data from preliminary assessment the researcher developed training sessions to improve preschool children’s’ knowledge and practice related to prevention and first aid maneuver of chocking .
• Each child and his parent (mother or father) were interviewed individually after explaining the purpose and method of the study. The interview took approximately 20 to 30 minutes to complete filling in the study tool I, depending upon the understanding and response of the child.
• Teach the group (5 preschool children and their parents) in the class the prevention and first aid of chocking using dull simulation.
• Data were collected during the period from beginning of September 2019 to the end of February 2020 from nursery school.
• Instructional handouts were developed by the researchers in simple Arabic language to explain the meaning of chocking, prevention, and first aid maneuver among children older than four years. Booklets were designed by the researchers, and then distributed to the participants.

Evaluation phase

The researchers met the preschool children after implementation the teaching session individually to evaluate the post supportive strategy test through assessment to their knowledge and reported practice regarding the prevention and first aid of chocking.

The Statistical Package for the Social Science (SPSS) version 20 was utilized for data entry, tabulation and analysis, which was applied to frequency tables, number and percentage, and standard deviation (SD), Significant at p \(\leq\) 0.05 Descriptive statistics were computed to summarize the studied preschool children and their parents’ characteristics.

Table 1 illustrated that, nearly two thirds of the studied preschool children were male (61%) and more than two thirds were aged 5 \(\leq\) years and more than two thirds of them included in KG2 (68% and 69%) respectively. About three quarters of them hadn’t any previous hearing about the prevention or first aid for choking (72%).

Table 2 illustrated that there was statistically significant difference between Preschool children’s’ knowledge regarding prevention and first aid of chocking before and after supportive strategy at p-value \(\leq 0.05\).

Figure 1 represented that nearly three quarters of the studied Preschool children had hadn’t any knowledge regarding choking (72%), and (9%) of them their source of knowledge regarding chocking teachers, while only (4%) from health care workers (doctors and nurses). Children mean total score of knowledge is given in Figure 2.

Figure 2: Children Mean Total Score of Knowledge

Figure 3 revealed that more than three quarters (89%) of the studied Preschool children had unsatisfactory knowledge score regarding prevention and first aid of chocking while only (3.5%) of them had good knowledge before supportive strategy compared to (78%) of them had satisfactory mean score of knowledge after supportive strategy. it was found that there was highly statistical significant differences between Preschool children total mean knowledge score before and after supportive strategy at p. value<0.001**

Figure 3: Children Source of Knowledge Regarding Chocking

Table 3 revealed that there was statistically significant difference between Preschool children mean reported practices regarding prevention of chocking before and after supportive strategy at p-value = (0.03).

Table 4 showed that there was statistically significant difference Preschool children mean practices regarding first aid of chocking before and after supportive strategy at (p-value\(\leq\)0.01).

Figure 4 revealed that more than three quarters (88 %) of the studied Preschool children had unsatisfactory practices score regarding prevention and first aid of chocking before supportive strategy compered to more than two thirds of them had good practices’ score (66.5%) after supportive strategy. it was found that there was highly statistical significant differences between children total mean practices score before and after supportive strategy at P. Value<0.001.

Figure 4: Children Mean Total Practice Score

Table 5 Showed that there was statistically significant difference between Preschool children’s’ total mean score of their knowledge and practice regarding prevention and first aid of chocking before and after supportive strategy at p-value = (0.035 and<0.001) respectively, with moderate and strong correlation before and after supportive strategy(r=0.456, 0.821) respectively.

Now and then we come across news of child death from aspiration of foreign objects. The unfortunate parts of all these events are most of them are preventable. It is needless to say that "Prevention is better than cure". The maneuvers are quite simple and can be given by anyone. Considering inquisitive nature of child, lack of awareness in society itself becomes a significant risk factor in choking. Working sincerely towards awareness about choking seems to be need of the hour [1]. The study has been conducted to evaluate the effect of supportive strategies regarding chocking prevention and first aid maneuvers among children.

Now and then we come across news of child death from aspiration of foreign objects. The unfortunate parts of all these events are most of them are preventable. It is needless to say that "Prevention is better than cure". The maneuvers are quite simple and can be given by anyone. Considering inquisitive nature of child, lack of awareness in society itself becomes a significant risk factor in choking. Working sincerely towards awareness about choking seems to be need of the hour [1]. The study has been conducted to evaluate the effect of supportive strategies regarding chocking prevention and first aid maneuvers among children.

As regard to personal characteristics of the studied present study illustrated that, nearly two thirds of the studied preschool children were male and more than two thirds were aged 5\(\leq\) years and included in KG2. About three quarters of them hadn’t any previous hearing about the prevention or first aid for choking these findings agree with [14] and [15] who reported that most of the children were boys were aged 5\(\leq\) years and included in KG2. While the present study contraindicated with [16] who reported that more than half of the studied sample were girls.

Concerning the preschool child’s knowledge the current study represented that nearly three quarters of the studied children had hadn’t any knowledge regarding choking, and (9%) of them their source of knowledge regarding chocking teachers, while only (4%) from health care workers (doctors and nurses). Based on this defect It was found that more than three quarters of the studied children had unsatisfactory knowledge score regarding prevention and first aid of chocking before supportive strategy compared to more than three quarters of them had satisfactory mean score of knowledge after supportive strategy. From my point of view, parents and teachers play an important role in educating preschool children and has an influence on their knowledge and practice.

The present study revealed that there was statistically significant difference between children mean reported practices regarding prevention of chocking before and after supportive strategy. This result agree with [17] who reported that educational program made a significant impact on both preschool children’s knowledge were successful in improving hand washing practices. Also, [18] stated that a previous study showed that repeated exposure to information through posters and campaigns is effective and it may be helpful to utilize methods or materials that could remind participants of knowledge about preventive behaviors.

Interpretation of the results should acknowledge some limitation as small sample size. Future studies should try to ensure that research should be performed in a facility that will offer an adequate sample size in order to validate findings.

Based on the study’s results it was concluded that; Children who received supportive strategy regarding prevention and first aid of chocking had improved their total knowledge and practices compared to before intervention, there were statistically significant difference between children’s’ total mean score of their knowledge and practice regarding prevention and first aid of chocking before and after supportive strategy.

Based on the study results, the following recommendations are proposed:

• Health promotion programs about chocking first aid and prevention should be directed to mothers, children care givers and teacher in all health care sittings and nursery school.
• Supportive strategies for families should be directed toward children under than five years.
• Community awareness regarding chocking prevention and how to provide first aid for children in emergency situations.

The authors wish to acknowledge all children who participated in the study, for their compliance and adherence to our supportive strategies about first aid and prevention for chocking among young children.

This research paper received no external funding.

The authors declare no conflicts of interest.

All authors contributed equally to this paper. They have all read and approved the final version.

Informed consent was obtained from all participates in the study as needed.

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