Assessment of knowledge, attitude and practice on first aid management of choking and associated factors among kindergarten teachers in Addis Ababa governmental schools, Addis Ababa, Ethiopia. A cross-sectional institution-based study

Ali Maalim Issack; Tilahun Jiru; Andualem Wubetie Aniley

doi:10.1371/journal.pone.0255331

. 2021 Jul 30;16(7):e0255331. doi: 10.1371/journal.pone.0255331

Assessment of knowledge, attitude and practice on first aid management of choking and associated factors among kindergarten teachers in Addis Ababa governmental schools, Addis Ababa, Ethiopia. A cross-sectional institution-based study

Ali Maalim Issack ¹, Tilahun Jiru ², Andualem Wubetie Aniley ^2,^*

Editor: Sergio García López³

PMCID: PMC8323944 PMID: 34329362

Abstract

Background

Choking refers to a blockage of upper airways by food or other objects resulting in interruption of breathing. It is a medical emergency that needs immediate action by anyone near by the victim to save life. Chocking is a major cause of illness and death in the pediatric population under the age of 5 years. Children at this age spent more time in their school and are at high risk during their feeding and playing. Immediate provision of first aid in response to choking by a preschool teacher will help to decrease the risk of developing life-threatening complications, length of hospital stays, the cost of treatment, and death.

Methods

Institutional-based cross-sectional study design was applied to the study area using pretested, structured, and self-administered questionnaires. The collected data were analyzed using SPSS version 25. Multiple logistic regression analysis was used to identify factors associated with Knowledge, attitude, and practice of kindergarten teachers towards first aid management of choking.

Results

A total of 224 Kindergarten teachers were involved in the study with a response rate of 95%. Only eighty-three (37%) of them were knowledgeable and 97 (43.3%) have faced a choked child in the school compound. Of these, only 42 (43.2%) had provided first aid to the victim. Most of the respondents 95.1% had a positive attitude towards choking first aid and 57.1% of them agreed that choking needs immediate management. Multiple logistic regression analysis showed that Kindergarten teachers with the previous first aid training were 2.9 times more knowledgeable than those kindergarten teachers without previous first aid training (AOR: 2.902, 95% CI: 1.612, 5.227)

Conclusions

The level of knowledge and skills for providing first aid for choking children among kindergarten teachers is low. There is a need for urgent intervention to train teachers regarding the provision of first aid for choking children.

Background

Choking refers to a blockage of upper airways by food or other foreign bodies resulting in interruption of breathing. It is an actual life-threatening emergency that needs immediate action by anyone nearby the victim to save a life [1]. Foreign bodies in the upper airway can cause acute obstruction leading to the onset of respiratory distress. It is common in children, who ingest objects as they pick up everything and place it in their mouths. Chocking is among the most common cause of injury-related morbidity and mortality especially under the age of 4 years [2, 3]. It is the major cause of illness and death in the pediatric population. Preschool-aged children are at higher risk for the choking incident because their behavior predisposes them to it [4]. The choking incident happens more frequently in young children as they play with the small item and put them in their mouths that may easily lodge into their airways resulting in an obstruction. If the air passage is not cleared, it can lead to loss of consciousness within 3–5 minutes. In worse cases, it results in hypoxia, and brain ischemia leads to death within few minutes [5]. Even if there are variations, the most common objects for choking on children are food, coins, toys, and balloons which commonly occur during feeding and playing [3]. Common signs and symptoms of choking include, cough, difficulty to breathe or talk, grasping the throat, and cyanotic appearance [6]. Choking can be managed with basic first aid skills applying a combination of abdominal thrust and back blow for children over one year. Abdominal thrust commonly called the Heimlich maneuver is a more effective technique of intervention to remove foreign body obstruction from the airway [1, 6, 7].

Studies showed that children are at increased threat for choking during school hours. Immediate provision of basic life support interventions by their teachers will prevent life-threatening complications. Kindergarten(KG) teachers are the major caregivers and first line of protection for KG school children replacing the role of parents [5, 8]. Educating and qualifying teachers in basic life support will help improve the survival of children for sudden out-of-hospital cardiac arrest. They will also teach children about first aid at the early stage of their life to know the preventive mechanism. Training teachers is easy to become competent in Basic Life Support (BLS) [9, 10]. Life-threatening conditions have a greater chance of happening at the educational institution since learners use more time at school and liable for accidents. Majority of an accident happening at preschool need immediate prehospital care intervention. As preschool teachers being the first respondent in the preschool setting, they need to be trained on first aid care to decrease illness and death related to an accident at the school [11].

Different teaching mechanisms have been proposed by organizations to educate about the prevention and management of choking. Different organizations like Red cross [12], American Heart Association [13], European Resuscitation Council [7] have developed guidelines for first aid management procedures including choking first aid. Many countries have used these guidelines to train their citizens for the prevention and treatment of choking first aid. Children are given special attention because of their susceptibility to choking [14].

Studies conducted in Iran, China, and Turkey showed that preschool teachers had inadequate knowledge and skills to handle an accident in a school setting [15–17]. A study conducted in Iraq reviled that most of the teachers have a low to moderate level of knowledge regarding chocking first aid management which was significantly associated with teaching years of experience. The study also showed that most of the teachers have good attitudes significantly associated with their age, marital status, educational background, and levels of experience [5]. Another study done in South Africa Cape town showed that only 12.1% of teachers have adequate knowledge of first aid management [18].

Previous studies done in Ethiopia on KAP of first aid found that KG teachers have inadequate knowledge and skill towards first aid [19, 20]. A study done in the Lideta sub-city of Addis Ababa showed that 40% of the participants have scored above the mean of knowledge questions and only 37.6% of them have good knowledge towards chocking first aid. Twenty-eight percent of preschool teachers identified choking students in the school setting [19].

As far as investigators’ knowledge, there is no study conducted in Ethiopia on choking first aid. Therefore, this study aimed to explore kindergarten school teachers’ choking first aid knowledge, attitude, and practice at government schools in Addis Ababa, Ethiopia.

Methods

Study setting and period

This study was conducted in selected public kindergarten schools in Addis Ababa city from March-1 to April 31, 2019. Addis Ababa is the capital city of Ethiopia which covers an area of about 520.14 km². It has ten sub-cities that encompass 116 districts. According to the National Population and Housing Census of Ethiopia projection figures in 2011, the total population of Addis Ababa is 2,980,001 with a proportion of male 47.64% and female 52.36% [21].

There are a total of 239 government kindergarten(KG) schools in Addis Ababa city with 1520 female and 43 male employed teachers [22]. The study was conducted at government KG schools in Bole, Gulele and kirkos sub-cities of Addis Ababa, Ethiopia.

Study design

Cross-sectional institution-based study design was conducted. The study was conducted in selected sub-cities of Addis Ababa governmental KG schools.

Sampling

A multistage random sampling technique was used. Based on the World Health Organization’s (WHO) 30% of minimum cluster size recommendation for resource-limited countries [23, 24], three sub-cities namely; Bole, Gulele and Kirkos sub-cities were selected with a simple random sampling method from ten sub-cities found in Addis Ababa city. Similarly, 22 districts from 37 were selected, and finally study was conducted on 22 schools from 50 in the districts of 3 sub citiess’ kindergarten schools (Fig 1).

The sample size was calculated using a single population proportion formula n = (Zα/2)² *p(1-p) /d2, by taking the assumptions as Zα/2 = 1.96 (standard normal value corresponding to 95% level of confidence), p = 0.5 (estimate of prevalence for KAP of chocking first aid to be 50%, since there is no similar study conducted in the study area), and d (margin of error) = 5%. The finite population correction formula was used for the study population less than 10,000 since the total population was 482 from 22 selected KG schools. After adjusting 10% for possible nonresponse rate, the final sample size was 235.

Data collection

Data were collected using pretested, structured self-administer questionnaire which consisted of socio-demographic information, knowledge questions, Attitude questions and Practice question of kindergarten teachers on first aid management of choking.

A questionnaire from previous investigations was modified and used [5, 7–9, 19, 25, 26]. The questionnaire has four parts;

Part one: consisted of socio-demographic characteristics of the teachers including age, sex, marital status, educational level, service year and previous first aid training.

Part two: of the questionnaire was designed to assess knowledge of teachers about choking first aid which has 11 multiple-choice questions. Each question has one correct answer, 1 correct and 0 incorrect answers with the minimum and maximum possible scores of 0 and 11Teachers scored the mean value and above of knowledge questions were considered to be knowledgeable.

Part three: consisted of seven questions focused to assess the attitude of KG teachers towards choking first aid using a five-point Likert scale with the value as follow; 1 score for strongly dis agree, 2 for disagree,3 for not sure, 4 for agree and 5 for strongly agree. Negative items were reverse coded and the answers to show low to a high level for the questions were negatively worded (1-strongly agree, 5 strongly disagree). Participants who responded agree and strongly agree have taken as positive(1) and those disagree and strongly disagree were negative attitude(0). The score mean and above for attitude questions was considered as positive attitude and below mean was negative attitude.

Part four: consists of 12 case-based multiple questions structured to assess teachers’ practice for the provision of chocking first aid. KG teachers who scored 80% and above of practice questions have good practice for choking first aid. The validity of the questionnaire was assessed and evaluated by experts specialized in the field related to the present study. The reliability of Cronbach’s Alpha test was = 0.802

The questionnaire was prepared in English language and translated to local Amharic language by experts and then translated back to the English version to ensure its consistency.

Four-degree holder nurses were collected the data who have trained for two days on clarification of some terms questionnaire and aim of the study. Concerning the need for strict confidentiality of respondents’ information, timely collection and reorganization of the collected data from respective kindergartens. KG teachers who were ill, on maternity leave, annual leave, and study leave, were excluded from the study.

Data quality management

Data were guaranteed during collection, coding, entry, and analysis for appropriate quality assurance. The questionnaire was pre-tested on 5% of the calculated sample size out of the study area before the actual data collection, on a similar population. Some modifications were made to the questionnaires according to the participants’ recommendations and the average time taken to fill the questionnaire was 10 minutes.

Supervisors and principal investigators have checked data collectors on how they were administering questionnaires to the study participants and completeness of data on a daily basis and feedback was given. Codes was given to the questionnaires during the data collection. Consequently, any problem encountered was discussed among the survey team and was solved as soon as possible. The collected were coded and entered Epi-Data version 7.0, cleaned, and finally transferred to SPSS version 25 for further analysis.

Data analysis

KG teachers’ Knowledge of first aid provision for choking was assessed using eleven questions. The questions were dichotomized to knowledgeable and not-knowledgeable. A score of mean value and above it was considered as knowledgeable, while less than the mean value taken as not-knowledgeable. Knowledge was taken as a dependent variable and independent variables were sex and age of participants, year of experience, marital status and previous first aid training. The variables were taken from previously studied literatures. Teachers’ attitude towards first aid management for chocked child was assessed by using a five-point Likert scale. Strongly agree-5, agree-4, neutral -3, disagree 2 and strongly disagree-1. A score of 5 and 4 were given for positive attitude while 2 and 1 were for negative attitude and the order of scoring for negative statements was reversed. Then, the score was dichotomized into positive and negative attitude for each question. Practice of teachers were described and summarized using descriptive statics.

Bivariate and Multivariate logistic regression analysis were used to identify factors associated with the knowledge, attitude, and practice of kindergarten teachers on first aid management of choking. Univariate logistic regression analysis was used to identify potential associated factors between dependent and independent variables. To control for the potential confounders, a multiple logistic regression model with backward selection was used. For those variables with level statistically significant (P <0.25), on univariate analysis were entered jointly into a multivariate logistic regression. All statistical tests were two-tailed, and the significance level was declared at p<0.05 with a 95% confidence level. Regression was applied to assess the association between dependent and independent variables

Ethics statement

Approved ethical clearance letter was obtained from Addis Ababa University health science college, department of emergency medicine ethical review committee. An official letter was written to Addis Ababa City administration Education bureau to grant permission to undertake a study. Permission was obtained from selected Sub City education bureau. Participants were informed verbally and those who were not volunteers had been permitted not to participate in the study. Informed written consent was obtained from respondents who had participated in the study. Confidentiality was maintained throughout the study by assuring that any information will never be passed to any third party or institution without their agreement.

Operational definition

Choking first aid–is the immediate care given to choking person until full medical treatment is available.

Adequate knowledge–a participant who scored a mean and above for knowledge questions.

Inadequate knowledge–a participant who scored below mean for knowledge questions.

Positive Attitude- a participant who answered agree and strongly agree for attitude questions and sored mean or above.

Negative attitude–a participant who answered disagree and strongly disagree for attitude questions and scored below mean.

Good Practice–a participant who scored 80%and above of practical questions (according to AHA pediatric basic life support and advanced life support 2020)

Poor practice–a participant who scored below 80%of practical questions (AHA, PBLS and PALS 2020)

Results

Socio-demographic characteristics

Out of 235 participants, 224 were correctly responded to the provided questions with a response rate of 95%. Most respondents,211(94.2%) were females with a female to male ratio of 16:1. The average age of the respondents was 30.79±7.26years. Concerning the educational level of the kindergarten teachers, the majority (152, 67.9%) had a certificate level(secondary school complete with additional two years teachers’ education training); which is a minimum requirement to be a KG teacher in Ethiopia and 2 (0.9%) were Bachelor Degree holders. Regarding the years of experience, 98 (43.8%) had less than five years of experience. The study revealed that the majority (122, 54.5%) had not taken previous first aid training (Table 1).

Table 1. Socio-demographic characteristics of kindergarten teachers among government schools in Addis Ababa Ethiopia, 2019.

	variable	Frequency	Percentage
sex	Male	13	5.8
sex	Female	211	94.2
Marital status	Married	111	49.6
	Single	110	49.1
	Divorced	3	3.1
Level of education	Certificate	152	67.9
	Diploma	70	31.3
	Degree	2	0.9
Years of experience	< 1 year	37	16.5
	1–5 years	98	43.8
	6–10 years	58	25.9
	>10 years	31	13.8
Age Groups	20–24	42	18.8
	25–29	67	29.9
	30–34	60	26.8
	35–39	28	12.5
	40 and older	27	12.1
Previous first aid training	Yes	102	45.5
Previous first aid training	No	122	54.5

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Knowledge of kindergarten teachers on first aid management of a choking child

Of all respondents, only 37% of KG teachers scored above the mean value of knowledge questions. One hundred thirty (58%) of participants have heard about first aid provision for a choking child. Thirty-nine of them (29%) heard it from health professionals and the rest from family members (27.6%) and media (26.1%). Majority of respondents,117(52.2%) did not know how to give first aid for a choking child. From those who know,40 (37.4%) learned it from health professionals and 3 (2.8%) from previous studies.

One hundred twenty (53.6%) of participated teachers were knowledgeable about the universal sign of choking. Eighty-four (37.5%) of teachers know risk factors for choking including improper chewing of food, immature molars, running and playing with food in their mouth and adventurous nature of preschool children.

Majority (50.9%) know that coin has a potential for causing a choking hazard while whole grapes (16.5%) and popcorn (4.9%) are the least to cause it. One hundred fifty-nine participants (71%) responded two minutes as a golden time for providing first aid while (6.7%) mentioned one hour. Concerning symptoms of complete airway obstruction, most of the participants 126 (56.3%) were knowledgeable and described it as an inability to produce sound and cough (Table 2).

Table 2. Respondent’s answers frequency and percent for specific questions on knowledge aassessment in Addis Ababa, Ethiopia, 2019.

Questions	Yes		No
Questions	Frequency	Percentage	Frequency	Percentage
The universal sign of choking	120	53.6	104	46.4
Factors led to choking among preschoolers	84	37.5	140	62.5
Potential choking hazard item	29	12.9	195	87.1
Golden time for providing choking first aid	9	4	215	96
Symptoms of complete airway obstruction	126	56.3	98	43.8
Symptoms of partial airway obstruction	59	26.3	165	73.7
Choking induced by aspiration of fluids	125	55.8	99	44.2

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Attitude of kindergarten teachers towards first aid management of choking

From the total participants, Majority (95.1%) of them scored the mean and above of attitude questions considered to have positive attitude towards providing first aid for a chocking child. One hundred twenty-eight (57.1%) and 66(29.5%) of participants agreed and strongly agreed that choking needs immediate management respectively. Similarly, most of the respondents, 153(68.3%) strongly agree that everybody should know about first aid management of choking. Ninety-nine (44.2%) strongly disagree that choking causes death or life-threatening condition if not treated. The majority,113(50.4%) agree that it was possible to manage choking at school without taking the victim to the health institution. Seventy-five (33.5%) strongly disagree that they should sweep their fingers blindly into the throat of a choked victim and 24 (10.7%) strongly agree to it. Majority of respondents 106 (47.3%) agreed not to provide first aid without proper knowledge on how to do it (Table 3).

Table 3. Attitude on choking first aid management among government kindergarten school teachers in Addis Ababa Ethiopia, 2019.

Question items	Strongly Agree	Agree	Disagree	Strongly disagree
Choking should need immediate management	66(29.5%)	128(57.1%)	23(10.3%)	7(3.1%)
Everyone should know about first aid management of choking	153(68.3%)	54(24.1%)	8(3.6%)	9(4%)
Choking does not cause death/life threatening condition even if not treated	12(5.4%)	31(13.8%)	82(36.6%)	99(44.2%)
It is possible to manage choking at school without taking a victim to the health hospital	49(21.9%)	113(50.4%)	43(19.2%)	19(8.5%)
We should sweep our fingers blindly into the throat of choked victim & take victim to health institution	24(10.7%)	57(25.4%)	68(30.4%)	75(33.5%)
You must not provide choking first aid without knowledge	35(15.6%)	106(47.3%)	56(25%)	27(12.1%)
If choking first aid is not given within golden time, it may lead to death	126(56.3%)	76(33.9%)	16(7.1%)	7(2.7%)

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Practice of kindergarten teachers on first aid management of choking

Majority of the participants, 123(54.9%) witnessed a choking episode outside the kindergarten. Among these, 63 (51.2%) had provided first aid. Ninety-seven (43.3%) were encountered a choking episode in kindergarten. Of these, 55 (56.7%) of them did not provide first aid. The reason for not providing first aid was lack of knowledge 79 (68.7%), fear of complications 19(16.5%), fear of medico-legal issues 13 (11.3%) and fear of communicable disease transmission 4 (3.47%).

Some participants 91(40.6%) prefer to give a glass of water for a choking child while 50 (22.3%) would hit the back of the neck and 167 (74.6%) send the victim to a health institution.

Seventy-eight (34.8%) of the respondents did not know the site of the body to provide choking first aid for complete airway obstruction while 52 (23.2%) would tap just below the neck and 29 (12.9%) would tap between shoulder blades and the base of the ribs. Ninety-eight participants (43.8%) would give a glass of water and call for an ambulance if they faced a child choking and coughing with complete airway obstruction and visible foreign body. And, seventy-six (33.9%) would contact the responsible school authority if the child lost consciousness and become breathless.

Based on assessed practical questions for complete airway obstruction management 67 (29.6%) would do a finger sweep, 152 (67.9%) would give water and 4 (1.8%) would give a piece of food (Table 4). Overall,97.8% of study participants had scored below 80% of practical questions they are considered to be poor practice towards first aid management of choking.

Table 4. Respondent’s answer for specific question on practice assessment among govenment kindergaten school teachers in Addis Ababa, Ethiopia, 2019.

Questions	Response	Frequency	Percentage
Faced choking victim outside school (n = 224)	Yes	123	54.9
Faced choking victim outside school (n = 224)	No	101	45.1
Given first aid n = 123	Yes	63	51.2
Given first aid n = 123	No	60	48.8
Faced a choking child in the school n = 224	Yes	97	43.3
Faced a choking child in the school n = 224	No	127	56.7
Action taken when faced child choking with complete Airway obstruction, object no visible	Giving a glass of water	91	40.6
	Do finger sweep to identify & remove object	16	7.1
	Hitting at the back of neck	50	22.3
	Abdominal thrust	24	10.7
	Slapping at the back	36	16.1
	Don’t know what to do	7	3.1
Action taken when faced a child choking, develop talking and breathing difficulty with visible and accessible foreign body.	Taking to health institution	51	22.8
	Notifying the school director	35	15.6
	Remove foreign object	26	11.6
	Hitting at the back of neck	54	24.1
	Giving a sip of water	42	18.8
	Abdominal thrust	14	6.3
	Chest thrust	2	0.9
Action taken when child is choking and coughing	Slap at the back	52	23.2
	Give a glass of water & call EMS	98	43.8
	Abdominal thrust	38	17
	Encourage a child to cough	22	9.8
	Chest thrust	14	6.3
Child choked, became breathlessness and unconsciousness	Contacted responsible school authority	76	33.9
	Slapped at the back	54	24.1
	Given two rescue breath and do CPR	59	26.3
	Begun to do CPR	11	4.9
	Don’t know what to do	22	9.8
	Hitting at the back of neck	1	0.45
	Did finger sweep	1	0.45

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Factors affecting knowledge of kindergarten teachers toward first aid management of choking

Binary and multiple logistic regression analysis were done to analyze factors associated with knowledge of providing choking for first aid. On the binary logistic regression analysis, sex, age, marital status, years of experience and previous first aid training were all associated with knowledge of first aid management for a chocked child. Previous first aid training experience was significantly associated with teachers’ knowledge of choking first aid management (AOR: 2.902, 95% CI: 1.612, 5.227, P ≤0.05). Demographic data of KG teachers has no association with their attitude and practice of choking firs aid (Table 5).

Table 5. Binary and multiple logistic regression analysis of selected factors affecting knowledge on first aid management of choking among government kindergarten school teachers in Addis Ababa, Ethiopia, 2019.

Variable		knowledge level		Linear regression (95% CI)
		Adequate	inadequate	COR(p<0.25)	p- value	AOR(P<0.05)	p- value
		Freq. (%)	Freq. (%)	COR(p<0.25)	p- value	AOR(P<0.05)	p- value
Sex	Male	7(3.1%)	6(2.7%)	1.729(0.562–5.325)	0.340	2.699(0.768–9.487)	0.122
Sex	Female	76(33.9%)	135(60%)	1		1
Age	20–24	10(23.8%)	32(76.2%)	1		1
	25–29	26(38.8%)	41(61.2%)	2.03(0.855–4.812)	0.108^*	2.117(0.780–5.747)	.141
	30–34	25(41.7%)	35(58.3%)	2.28(0.952–5.489)	0.06^*	2.224(0.790–6.262)	0.13
	35–39	8(28.6%)	20(71.4%)	1.28(0.433–3.787)	0.656	1.278(0.373–4.378)	0.696
	40 and older	14(51.9%)	13(48.1%)	3.45(1.222–9.712)	0.019^**	2.845(0.758–10.674)	0.121
Experience	< 1 yrs.	14(37.8%)	23(62.2%)	1		1
	1-5yrs.	37(37.8%)	61(62.2%)	0.440(0.166–1.165)	0.098^*	0.611(0.238–1.572)	0.307
	>5–10 yrs.	23(39.7%)	35(60.3%)	0.438(0.193–0.997)	0.049**	0.513(0.182–1.446)	0.207
	>10 yrs.	18(58.1%)	13(49.9%)	0.475(0.196–1.152)	0.099^*	0.611(0.169–2.202)	0.451
Previous first aid training	Yes	58(56.9%)	44(43.1%)	3.149(1.810–5.478)	<0.001^*	2.902(1.612–5.227)	< 0.001^**
Previous first aid training	No	25(20.5%)	97(79.5%)	1		1

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** = significant at p≤ 0.05

* = associated at p≤ 0.25, COR-crude odes ration, AOR-adjusted odes ration.

Discussion

Adequate knowledge and skills of kindergarten teachers can help in the prevention and reduction of morbidity and mortality related to choking episodes in the KG school compound. The teachers play a major role in the management of these emergencies. Training basic life support including choking first aid will improve the survival of children related to chocking in the school environment [9].

The knowledge and skill of kindergarten teachers towards choking first aid management for choked children in this study was inadequate. Only 37% of KG teachers scored above the mean value of knowledge questions. The absence of compulsory first aid management during kindergarten teachers’ training in Ethiopia could be the reason for this finding. The finding of this study was in line with the studies conducted in other countries; In Iraq, most of teachers had poor knowledge [5] and in India, 6 out of 146 teachers have good knowledge about first aid provision of a chocking child [8] and in China, only 30.1% answered correctly for first aid management of chocking [16]. A study done in South Africa Cape town also showed that only 12.1% of teachers have adequate knowledge on first aid management [18]. But a study conducted in Egypt was higher than our finding in that majority of teachers were knowledgeable towards first aid management of chocking [27]. The difference may be study method and availability of training facilities in Egypt.

This study showed that 45.5% of KG teachers have trained in first aid. It is lower than studies done in Iraq 73.5% [5]. South Africa, Cape town 74% [18] and Turk 73.6% [17] of the teachers received first-aid training. This is might be countries included first aid training in their educational curriculum as a course and mandatory to train.

Our study finding showed that teachers’ previous first aid training experience had significantly associated with knowledge of chocking first aid management (AOR: 2.902, 95% CI: 1.612, 5.227, p<0.05). Kindergarten teachers with previous first aid training experience were about three times more knowledgeable than those who had not it. This is similar to a previous study done in Ethiopia where kindergarten teachers with the previous first aid training were three times more likely knowledgeable compared to those who had no training [19]. Similarly, studies conducted in China and Iran revealed significant association between previous first aid training and knowledge [15, 16].

Inadequate knowledge in the current study may be related with lack of first aid training given for KG teachers and not included it as a course in their curriculum.

Majority of respondents agreed that choking needs immediate management which was in line with the study done in Iraq [5].

The present study indicated that most of teachers’ attitudes about first aid of choking were positive. This study is similar to a study done in Iraq where most of teachers were found to have a positive attitude toward first aid [5]. It is also comparable with a study conducted in Spain where more than 80% of the participants have agreed that everyone should have basic first aid knowledge [10]. The majority of study participants had poor practice, moreover a significant number of kindergarten teachers had bad and dangerous practices toward a choking victim like hitting at the back of the neck, putting fingers into the throat of a victim blindly, giving water to drink and blowing at the fontanel of the victim. The study finding is used as a baseline to intervene such malpractice for policymakers and responsible stakeholders for curriculum revision incorporating first aid training courses.

The limitation of this study are; One of the limitations is the study design being cross-sectional in that cause and effect association cannot be studied. Second, there may be a bias related with participants’ level of understanding since the data collection tool was a self-administered questionnaire. Finally, lack of sufficient similar studies made limit comparison with other studies. Different mechanisms were tried to minimize bias. Some of these were performing pre-tests before actual data collection. Data collectors were explained to participants about the aim of the study, unclear ideas, and anything before and during data collection time.

Conclusion

The knowledge and practice of kindergarten teachers towards provision of first aid for a choking child is low while their attitude is positive. The majority of teachers have encountered chocked children and provided first aid with a non-standard provision and some even had a life-threatening practice towards a choked victim. Having previous experience of first aid was significantly associated with knowledge of choking first aid provision. This needs urgent intervention to train teachers on first aid provision towards chocking management. It is recommended that first aid training is included in the kindergarten teachers’ education curriculum as a course.

Supporting information

S1 File

(DOCX)

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Acknowledgments

We thank Addis Ababa University for providing us to conduct this study and its ethical approval. We also thank to administrators in the study schools who helped contact teachers for the survey. Lastly, Supervisor, Data collectors and study participants are to be thanked for their immense cooperation during data collection period.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

References

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PLoS One. doi: 10.1371/journal.pone.0255331.r001

Decision Letter 0

Yann Benetreau

26 Apr 2021

PONE-D-20-32556

Assessment of knowledge, attitude and practice on first aid management of choking and associated factors among kindergarten teachers in Addis Ababa Governmental Schools, Addis Ababa, Ethiopia. A cross-sectional institution-based study

PLOS ONE

Dear Dr. Wubetie,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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[We thank Addis Ababa University for supporting and providing funding for this study. Jigjiga University should be thanked for its unreserved support and sponsorship. Lastly, Supervisor, Data collectors and study participants are to be thanked for their immense cooperation during data collection period.]

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Comments to the Author

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Good effort by the authors. However, there are some major concerns which are explained section wise as under

1. Introduction : Text is not supported with appropriate updated references .

There is a statement "As far as investigators’ knowledge, there is no study conducted in Ethiopia on chocking first aid". This study is part thesis submitted to Addis Ababa University, for partial fulfilment of the requirement for degree of masters in emergency medicine and critical care nursing and already available online .

2. Methods : Sampling technique multistage sampling is not clearly described

Sample size estimation is not correct

Data Collection tool : Development and validation of tool is not described adequately

Data collection procedure , inclusion & exclusion criteria is not clear

3. Results : How were the main outcomes of knowledge and practice adequacy defined? Please provide rationales for choosing the cut-off points for positive attitudes and adequate practice?

What was the response rate? How many school teachers were approached and out of them how many actually participated in study.

4. Discussion: Findings about factors associated with knowledge and skills of kindergarten teachers in the prevention and reduction of morbidity and mortality are not adequately compared with literature elsewhere, most of the study cited are from Ethiopia

5. Conclusion : The data presented in the manuscript must support the conclusions drawn. Conclusion mentioned in abstract and main manuscript are contradictory .

Implications of the findings, and what steps are needed to address the gaps are not addressed .The implications of this study on the generalizability of findings within Ethiopia are not addressed.

Please proofread and correct grammatical errors throughout the paper, there are lot of grammatical and spelling mistakes through out the manuscript. Need to revise to ensure that it is written in intelligible fashion and in standard English language .

Reviewer #2: First of all, I would like to share the need to carry out work like the one you present. They are necessary for the advancement of science in this sector. Life is the most important of all and even more so knowing how to intervene in the early stages of life as educators.

Thank you for allowing me to review this interesting study. Overall, the study has raised a very interesting point of discussion. I think this study has provided novel findings in this area in your country.

The specific term should be included according to the protocol established in the Basic Life Support (BLS) guidelines of the ERC (European Resuscitation Council) or AHA (American Heart Association) institutions.

The appropriate concept is OVACE (Foreign Body Airway Obstruction). It should be included since researchers and readers who work in the field of first aid is the term that refers to the objective of the proposed work. Review the reference institution in their continent and adapt the concept so that the international community knows what the work refers to.

Add the specific term to which the choking refers as a keyword.

It should be clarified that the training that kindergarten teachers have, since the authors reflect that 2 are graduates and 67.9% have a professional certificate. What is the training required to be able to practice in this age group in your country? It is understood that the study plans of these trainings do not teach first aid content, right?

I would like the authors to make a detailed explanation about the questionnaire to which the sample has been submitted. I would like to be able to analyze it, as well as describe the procedure to validate the instrument. It is true that they do it in the manuscript (in short), but I would like to know the procedure to follow in a more detailed way. As well as the statistical tests that have been carried out, both for the selection of the sample, and to pass it to 5% of the target population, to finally validate it and make it a valid and reliable instrument.

Reviewer #3: Authors present an interesting study about knowledge and attitudes towards choking management of kindergarten teachers. The importance of the topic is indubitable; schoolteachers have to be trained in choking management and first aid. However, the manuscript should be revised prior publication in an international journal. In first place, English must be revised, as well as all the mistakes and errors (some of them included in this review). In addition, the description of the results is redundant, duplicating data from the tables Please, see some comments and recommendations below:

Introduction:

l.61-62: Studies carried out in Iran, China and Turkey are mentioned. However, only two references (9 & 15) are placed into the text. Due to the limited literature existing about this topic, and the international readership of PLoS ONE, authors should try to include the majority of researches published in international journals. In this regard, there are studies published in other countries (i.e. Spain) in which schoolteachers (primary and pre-school) were asked for basic life support knowledge, including foreign body airway obstruction.

Methods:

It would be helpful to have the questionnaire. Please, add it as supplementary file. It cannot understand results reported in the tables without the main questionnaire. In addition, a better description of the questionnaire should be included.

l.116: “The variables were taken from previously studied literatures”. Which ones?

How was the questionnaire administered? How long did fill the questionnaire take?

Three sub-cities were randomly selected; but, why three?

Please, re-design Figure 1 to become more understandable.

l. 92-93: Please, replace “Data collection tool was adopted and modified from previously studied literatures (4),(13),(8) and (12)” with “A questionnaire from previous investigations were used (4,12,13,18)”.

Please, be consistent in the description of the results using both, absolute and relative frequencies, and only one decimal.

It is not clear how authors calculate the level of knowledge of KG teachers.

In expressions like (l.144) “Most respondents 211 (94.2%)…”, the absolute frequency cannot be included in the text in this way, it has to be in brackets or square brackets. Please, correct this in the whole manuscript.

Results:

Authors stated that the 37% of the KG teachers had adequate knowledge; based on what? It was not reported any data about what is adequate/inadequate knowledge.

Table 2: “Frecuency cy”. It should be corrected.

L.179-180: What does it mean that majority of the respondents have positive attitude towards providing first aid for a choking child? How did this data calculated?

Authors stated that 57.1% agreed that choking needs immediate management. Why did not you talk about those KG teaches who strongly agreed? This is an example that the description of the results in the texts is a duplication of the information reported in the tables. This has to be corrected in all the manuscript. Continuing with this example, if somebody strongly agree with something, at the same time agree; thus, although in the table the results are split in function of the questionnaire responses, in the text description it has to be used another way in order to avoid duplicate information.

Table 3: “Uncerta Disagree in N(%) N (%)”. It should be corrected.

Please, replace “Percent” with “Percentage” in all tables.

What do you mean with “Seventy-eight (34.8%) of the respondents did not know where to provide first aid”?

Table 5: Please, remove all data regarding no significant differences. “0.000” must not be used; it has to be replaced with “< 0.001”. CI lower and upper bounds should be separated by “-“. In addition, results of Table 5 should be revised; there are high differences between COR and AOR, is this correct? For example, in the case of Age (25-29), 0.156 becomes in 5.889.

Discussion:

Discussion should be start summarizing the main findings. Then, it should be follow the same order than results. The association between first aid training and knowledge was the last result reported, but it the first result discussed. Please, be consistent in this regard.

Again, the manuscript cited from China has no reference (l.237-238).

L.238-239: It does not understand the following sentence: “But a study finding in Egypt was higher than our finding where majority of teachers were knowledgeable towards first aid management of chocking”

Discussion should address how to achieve that KG teachers train in first aid matters as choking management; for example, including this contents in university degrees, which was recommended in previous publications. The following references should be to take into account to complement the introduction and the discussion:

https://doi.org/doi:10.1016/j.anpede.2018.10.013

https://doi.org/10.1097/EJA.0000000000001272

https://doi.org/10.1007/s00431-021-03971-x

https://doi.org/10.1016/j.resuscitation.2020.04.021

https://doi.org/10.1016/j.anpede.2019.10.005

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PLoS One. 2021 Jul 30;16(7):e0255331. doi: 10.1371/journal.pone.0255331.r002

Author response to Decision Letter 0

7 Jun 2021

To editor

Thank you for giving me the opportunity to submit a revised draft of my manuscript titled - knowledge, attitude, and practice on first aid management of choking and associated factors among kindergarten teachers in Addis Ababa Governmental Schools, Addis Ababa, Ethiopia to PLOS ONE. I appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on my manuscript. I am grateful to the reviewers for their insightful comments on my paper. I have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. I have highlighted in blue the changes within the manuscript. I hope it will now be suitable for publication in the PLOS ONE.

With regards

Andualem Wubetie, MSc

Here is a point-by-point response to the reviewers’ comments and concerns.

Comments from the editor

Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming

Response: Thank you for your comment. We corrected it with PLOS ONE's style requirements.

Comment 2: Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses

Response: Thank you also for this comment. We have revised and corrected it.

Comment 3: We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript.Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement

Response: Thank you for pointing these out. We agree with these comments. Therefore, we have corrected in the manuscript.

Comments from Reviewer

Reviewer 1:

Comment 1: . Introduction :

1- Text is not supported with appropriate updated references.

Response: Thank you for pointing this out. We agree with this comment. Even if there is shortage of references, we have tried to correct.

2: There is a statement "As far as investigators’ knowledge, there is no study conducted in Ethiopia on chocking first aid". This study is part thesis submitted to Addis Ababa University, for partial fulfilment of the requirement for degree of masters in emergency medicine and critical care nursing and already available online

Response: This is correct. This study is done for partial fulfilment of the requirement for degree of masters in emergency medicine and critical care nursing in Addis Ababa University and submitted to Addis Ababa university library which is a rule of the university for graduation requirement. We submitted this study to PLOS ONE for publication.

comment 2: Methods :

Sampling technique multistage sampling is not clearly described

Sample size estimation is not correct

Data Collection tool : Development and validation of tool is not described adequately

Data collection procedure , inclusion & exclusion criteria is not clear

Response: Thank you also for pointing out this We have modified and tried to describe this point clearly.

Comment 3: Results :

How were the main outcomes of knowledge and practice adequacy defined? Please provide rationales for choosing the cut-off points for positive attitudes and adequate practice?

What was the response rate? How many school teachers were approached and out of them how many actually participated in study?

Response: Thank you for the comments. We have tried to correct it in the manuscript.

Comment 4: - Discussion: Findings about factors associated with knowledge and skills of kindergarten teachers in the prevention and reduction of morbidity and mortality are not adequately compared with literature elsewhere, most of the study cited are from Ethiopia

Response: We agree, we have modified and tried to describe pertinent findings of our study with previously done to emphasize this point.

Comment 5: Conclusion :

The data presented in the manuscript must support the conclusions drawn. Conclusion mentioned in abstract and main manuscript are contradictory .

Implications of the findings, and what steps are needed to address the gaps are not addressed .The implications of this study on the generalizability of findings within Ethiopia are not addressed.

Response: We agree with the points out. We have tried to correct your suggestion in the manuscript

Reviewer 2:

Comment 1: The specific term should be included according to the protocol established in the Basic Life Support (BLS) guidelines of the ERC (European Resuscitation Council) or AHA (American Heart Association) institutions

Response: Thank you for pointing out this. We corrected it.

Comment 2:The appropriate concept is OVACE (Foreign Body Airway Obstruction). It should be included since researchers and readers who work in the field of first aid is the term that refers to the objective of the proposed work. Review the reference institution in their continent and adapt the concept so that the international community knows what the work refers to.

Add the specific term to which the choking refers as a keyword

Response: We agreed and corrected it.

Comment 3: It should be clarified that the training that kindergarten teachers have, since the authors reflect that 2 are graduates and 67.9% have a professional certificate. What is the training required to be able to practice in this age group in your country? It is understood that the study plans of these trainings do not teach first aid content, right?

Response: we revised and tried to clarify it in the manuscript.

Comment 4: I would like the authors to make a detailed explanation about the questionnaire to which the sample has been submitted. I would like to be able to analyze it, as well as describe the procedure to validate the instrument. It is true that they do it in the manuscript (in short), but I would like to know the procedure to follow in a more detailed way. As well as the statistical tests that have been carried out, both for the selection of the sample, and to pass it to 5% of the target population, to finally validate it and make it a valid and reliable instrument.

Response: thank you for pointing out this. We have revised and tried to explain in detail.

Reviewer 3:

Comment 1: Introduction:

Response: Thank you for your comment. We have added and tried to correct in the manuscript

Comment 2: Methods:

l.116: “The variables were taken from previously studied literatures”. Which ones?

How was the questionnaire administered? How long did fill the questionnaire take?

Three sub-cities were randomly selected; but, why three?

Please, re-design Figure 1 to become more understandable.

Please, be consistent in the description of the results using both, absolute and relative frequencies, and only one decimal.

It is not clear how authors calculate the level of knowledge of KG teachers.

Response: Thank you for pointing out these constructive comments. We agreed on comments and corrected accordingly.

Comment 3: Results:

Comment 3.1 Authors stated that the 37% of the KG teachers had adequate knowledge; based on what?

Response: It is the total participants’ who scored mean and above mean of knowledge questions.

Comment 3.2: It was not reported any data about what is adequate/inadequate knowledge.

Response: we reported in table form for all knowledge questions how much they answered or knowledgeable and also tried to explain major findings in sentence.

Comment 3.3: L.179-180: What does it mean that majority of the respondents have positive attitude towards providing first aid for a choking child? How did this data calculated?

Response: respondents scored above mean of attitude questions or agree and strongly agree respondents were considered to have positive attitude.

Comment 3.4: Authors stated that 57.1% agreed that choking needs immediate management. Why did not you talk about those KG teaches who strongly agreed? This is an example that the description of the results in the texts is a duplication of the information reported in the tables. This has to be corrected in all the manuscript. Continuing with this example, if somebody strongly agree with something, at the same time agree; thus, although in the table the results are split in function of the questionnaire responses, in the text description it has to be used another way in order to avoid duplicate information.

Response: Thank you for the constructive comment. We corrected it throughout the manuscript.

Table 3: “Uncerta Disagree in N(%) N (%)”. It should be corrected.

Please, replace “Percent” with “Percentage” in all tables.

What do you mean with “Seventy-eight (34.8%) of the respondents did not know where to provide first aid”?

Response: Thank you also for pointing out these points. We have modified and tried to describe these in the manuscript.

Comment 4: Discussion:

Again, the manuscript cited from China has no reference (l.237-238).

Response: We agreed with the comments and tried to correct it accordingly.

Additional clarifications

In addition to the above comments, spelling and grammatical errors pointed out by the reviewers have been tried to correct.

We look forward to hear from you in due time regarding our submission and to respond to any further questions and comments you may have.

Sincerely,

Andualem Wubetie Aniley

PLoS One. doi: 10.1371/journal.pone.0255331.r003

Decision Letter 1

Sergio García López

23 Jun 2021

PONE-D-20-32556R1

PLOS ONE

Dear Dr. Andualem Wubetie, Msc

Please submit your revised manuscript by 06/30/2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Sergio García López, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Dear author,

First of all, I have to thank you for the effort you have made so far with your manuscript.

I think it is a work that will be a reference in your country on the subject of study.

However, there are some considerations that the reviewers have made that you have not addressed. I invite you to be able to review and correct them. In addition, those that are not carried out, the justified reason must be detailed in order to be evaluated by the editorial committee.

Likewise, they have been emphasized in the incorporation by a reviewer of some references that are considered essential for their work. Keep in mind that there are not many scientific studies in this matter, and the existing ones should be reflected, since this facilitates the advancement and contrast of the results and consequently, scientific knowledge advances.

I invite you to review these questions and make small corrections in order to be successful in this last phase of the process.

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2021 Jul 30;16(7):e0255331. doi: 10.1371/journal.pone.0255331.r004

Author response to Decision Letter 1

27 Jun 2021

To editors,

With regards

Andualem Wubetie, MSc

Here is a point-by-point response to the reviewers’ comments and concerns.

Comments from the editor

Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming

Response: Thank you for your comment. We corrected it with PLOS ONE's style requirements.

Comment 2: Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses

Response: Thank you also for this comment. We have revised and corrected it.

Response: Thank you for pointing these out. We agree with these comments. Therefore, we have corrected in the manuscript.

Additional comments from editors

Comment 1: Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: Thank you for adding these essential comments. We have revised references based on the referencing style for its completeness and correct order using updated citation manager. In addition, we have incorporated relevant current references and to cite suggestive evidences based on comments raised from reviewers. Additional references are (2, 5-8,10-12,22,23,26)

2. REPUBLIC OF GUYANA, Ministry of Public Health. Standard Treatment Guidelines for Primary Health Care. second edition. Guyana; 2015. 4–5 p.

5. Ibrahim H. Mustafa SSH. KNOWLEDGE AND ATTITUDE OF PRIMARY SCHOOL TEACHERS REGARDING CHOKING’S FIRST AID IN ERBIL CITY- KURDISTAN REGION - IRAQ. 2016 Oct;8(2):37–9.

6. Narayanan T. MN Med C, Med PF. Awareness , attitudes and practices of first aid among school teachers in Mangalore south India. 2015;7(4):274-81.

7. Georgiou M, Koenraad G Monsieurs, Nikolaos Nikolaou. KIDS SAVE LIVES: ERC Position statement on schoolteachers’ education and qualification in resuscitation. ELSEVIER,EUROPEAN RESUSCITATION COUNCIL. 2020 Oct 25;2020:8 7 _9 0.

8. Cristian Abelairas-Gómez, Aida Carballo-Fazanes, Santiago Martínez-Isasid,Sergio López-García, Javier Rico-Díazb, Antonio Rodríguez-Núnez. Knowledge and attitudes on first aid and basic lifesupport of pre- and elementary school teachers andparents. analesdepeditria. 2019 Oct 27;1–6. /.

10. The British Red Cross Society British Red Cross First Aid Resources. [2020-05-20]. https://www.redcross.org.uk/first-aid/.

11. American Heart Association AHA information. 2020. May 25, [2020-05-25]. https://www.heart.org/.

12. Robert Greif, Lockey A, Jan Breckwoldt, Patricia Conaghan. European Resuscitation Council Guidelines 2021: Education for resuscitation. ELSEVIER, R E S U S C I T A T I O N. 2 0 2 1;161(2021):3 8 8-4 0 7.

22. Steve Bennett," lony Woods;, Winith M. Iiyanage & Duane . Smithd. SIMPLIFIED GENERAL METHOD FOR (CLUSTER-SANllabE SURVEYS OF WEALTH IN DEVELOPING GObfNTIFSfilES. 1991;44.

23. Public Health Regional, Surveillance Team,Steven Ramsey. A Guide to Sampling for Community Health Assessments and Other Projects. N C Cent Public Health Prep. :1–5.

26. Shaima Shaban Mohamad, Dr. Afkar Ragab Mohamad. First Aid Program For Nursery School Teachers,Egypt. 2018 Aug;7(4):01–9.

Comment 2: There are some considerations that the reviewers have made that you have not addressed. I invite you to be able to review and correct them. In addition, those that are not carried out, the justified reason must be detailed in order to be evaluated by the editorial committee.

Response: Thank you for pointing out these that we did not addressed. We have corrected comments in the manuscript but not incorporated in the response letter assumed to be seen in the manuscript. Now, we have done it for every comment.

Comment 3: Reviewers have been emphasized in the incorporation by a reviewer of some references that are considered essential for their work. Keep in mind that there are not many scientific studies in this matter, and the existing ones should be reflected, since this facilitates the advancement and contrast of the results and consequently, scientific knowledge advances.

Response: We have incorporated essential current references in the manuscript.

Comments from Reviewer

Reviewer 1:

Comment 1: . Introduction :

1- Text is not supported with appropriate updated references.

Response: Thank you for pointing this out. We agree with this comment. Even if there is shortage of references, we have tried to correct.

comment 2: Methods :

1.Sampling technique multistage sampling is not clearly described

Response: Thank you. We have tried to describe clearly with evidence used sampling technique.

2. Sample size estimation is not correct

Response: Thank you for insight comment for sample size estimation. We have explained it how sample was calculated and estimated in the manuscript.

3. Data Collection tool : Development and validation of tool is not described adequately

Response: Thank you for advising us to describe adequately about it. We have tried to describe adequately about data collection tool and its development and validation with evidenced citation in the manuscript.

4. Data collection procedure , inclusion & exclusion criteria is not clear

5. Response: Thank you also for pointing out this. We have modified and tried to describe this point clearly in the manuscript.

Comment 3: Results :

1. How were the main outcomes of knowledge and practice adequacy defined? Please provide rationales for choosing the cut-off points for positive attitudes and adequate practice?

Response: Thank you. We have added operational definition for these terms as:

Adequate knowledge – a participant who scored a mean and above for knowledge questions.

Inadequate knowledge – a participant who scored below mean for knowledge questions.

Positive Attitude- a participant who answered agree and strongly for attitude questions.

Negative attitude – a participant who answered disagree and strongly disagree for attitude questions.

Good Practice– a participant who scored 80%and above of practical questions (according to AHA pediatric basic life support and advanced life support 2020)

Poor practice – a participant who scored below 80%of practical questions(AHA,PBLS and PALS 2020)

What was the response rate? How many school teachers were approached and out of them how many participated in study?

Response: Thank you for the comments. Out of 235 participants, 224 were correctly responded the provided questions with a response rate of 95%. We have tried to correct it in the manuscript. (p-8-line 200-202)

Response: Thank you for suggesting this comment., We have modified and tried to describe pertinent findings of our study with previously done to emphasize this point.(p-15-16)

Comment 5: Conclusion :

The data presented in the manuscript must support the conclusions drawn. Conclusion mentioned in abstract and main manuscript are contradictory .

Implications of the findings, and what steps are needed to address the gaps are not addressed .The implications of this study on the generalizability of findings within Ethiopia are not addressed.

Response: We agree with the points out. We have tried to correct your suggestion in the manuscript

Reviewer 2:

Response: Thank you for pointing out this. We incorporated it in our manuscript with updated references(p 3-4, line 70 -75)

Response: Thank you for your advice. We have incorporated these points in our manuscript(p-3, line 46-50)

Comment 3: Add the specific term to which the choking refers as a keyword

Response: we added it as key word.

Comment 4: It should be clarified that the training that kindergarten teachers have, since the authors reflect that 2 are graduates and 67.9% have a professional certificate. What is the training required to be able to practice in this age group in your country? It is understood that the study plans of these trainings do not teach first aid content, right?

Response: Thank you for your insight comment and advice. certificate level(secondary school complete with additional two years teachers education training); which is a minimum requirement to be KG teacher in Ethiopia and 2 (0.9%) were Bachelor Degree holders. We revised and tried to clarify it in the manuscript ( p-8,line 203-205). There is no first aid training in their curriculum. So, we recommended the responsible bodies to incorporate it. But we assessed educational level if it might be a factor for knowledge, attitude or practice for chocking first aid.

Comment 5: I would like the authors to make a detailed explanation about the questionnaire to which the sample has been submitted. I would like to be able to analyze it, as well as describe the procedure to validate the instrument. It is true that they do it in the manuscript (in short), but I would like to know the procedure to follow in a more detailed way. As well as the statistical tests that have been carried out, both for the selection of the sample, and to pass it to 5% of the target population, to finally validate it and make it a valid and reliable instrument.

Response: thank you for pointing out this. We have revised and tried to explain in detail in the manuscript with track changed highlighted in blue (p, 5-6)

Reviewer 3:

Comments : Introduction:

comment 1: . l.61-62: Studies carried out in Iran, China and Turkey are mentioned. However, only two references (9 & 15) are placed into the text.

Response: Thank you. We corrected it (p-4, line 76-77)

Comment 2: Due to the limi;ted literature existing about this topic, and the international readership of PLoS ONE, authors should try to include the majority of researches published in international journals. In this regard, there are studies published in other countries (i.e. Spain) in which schoolteachers (primary and pre-school) were asked for basic life support knowledge, including foreign body airway obstruction.

Response: Thank you for your suggestion to add these studies. We have incorporated in the manuscript introduction and discussion part.

Methods:

Comment 1: It would be helpful to have the questionnaire. Please, add it as supplementary file. It cannot understand results reported in the tables without the main questionnaire. In addition, a better description of the questionnaire should be included.

Response: Thank you for pointing out it. We have attached the questionnaire as supplementary file both English and local language (Amharic) version. We used Amharic version to collect the data. We have described clearly in the manuscript. (p,5-6, line 118-138)

comment 2: l.116: “The variables were taken from previously studied literatures”. Which ones?

How was the questionnaire administered? How long did fill the questionnaire take?

Response: thank you: we have clearly described it in the manuscript of methodology part( p,5-6). Average time taken to fill questionnaire was 10 minute(p,6, line 150)

Three sub-cities were randomly selected; but, why three?

comment 3: Please, re-design Figure 1 to become more understandable.

Response: we have redesigned with more clear form (see attached figure 1)

Comment 4: l. 92-93: Please, replace “Data collection tool was adopted and modified from previously studied literatures (4),(13),(8) and (12)” with “A questionnaire from previous investigations were used (4,12,13,18)”.

Response: We corrected it (p,5, line 121).

comment 5: Please, be consistent in the description of the results using both, absolute and relative frequencies, and only one decimal.

Response: Thank you. we corrected based on comments.

comment 6: It is not clear how authors calculate the level of knowledge of KG teachers.

Response: Thank you. We have used the mean score of knowledge questions to calculate participants’ level of knowledge. To say knowledgeable, we used a score of mean and above of knowledge questions. Please see descriptions more in the manuscript with track change highlighted in blue (p,5. Line 123-128).

comment 7: In expressions like (l.144) “Most respondents 211 (94.2%)…”, the absolute frequency cannot be included in the text in this way, it has to be in brackets or square brackets. Please, correct this in the whole manuscript.

Response: Thank you for pointing out comments. We have written the manuscript based on the previously published article style and corrected accordingly.

Results:

Comment 1: Authors stated that the 37% of the KG teachers had adequate knowledge; based on what?

Response: It is the total number of participants’ who scored mean and above mean of knowledge questions.

Comment 2: It was not reported any data about what is adequate/inadequate knowledge.

Response: we reported in table form for all knowledge questions how much they answered or knowledgeable and tried to explain major findings in sentence as knowledgeable and not (p,9-10)

Cooment 3: Table 2: “Frecuency cy”. It should be corrected

Response: Thank you. We corrected it. (p,10. Line 234-235)

Comment 4: L.179-180: What does it mean that majority of the respondents have positive attitude towards providing first aid for a choking child? How did this data calculated?

Response: Respondents answered attitude questions as agree and strongly agree were considered to have positive attitude. Attitude questions were dichotomized as positive attitude and negative attitude. The score mean and above attitude question was considered as positive attitude and below mean was negative attitude.

Comment 5: Authors stated that 57.1% agreed that choking needs immediate management. Why did not you talk about those KG teaches who strongly agreed? This is an example that the description of the results in the texts is a duplication of the information reported in the tables. This has to be corrected in all the manuscript. Continuing with this example, if somebody strongly agree with something, at the same time agree; thus, although in the table the results are split in function of the questionnaire responses, in the text description it has to be used another way in order to avoid duplicate information.

Response: Thank you for the constructive comment. We corrected it throughout the manuscript.

Comment 6: Table 3: “Uncerta Disagree in N(%) N (%)”. It should be corrected.

Response: Thank you. We have corrected (p,11. Line 250-251)

Comment 7: Please, replace “Percent” with “Percentage” in all tables.

Response : Thank you. We have corrected it.

Comment 8: What do you mean with “Seventy-eight (34.8%) of the respondents did not know where to provide first aid”?

Response: it is to mean the site of our body to provide first aid (Heimlich man over or back slap) for complete airway obstruction. (p,15. Line 260-261).

Comment 9: Table 5: Please, remove all data regarding no significant differences. “0.000” must not be used; it has to be replaced with “< 0.001”. CI lower and upper bounds should be separated by “-“. In addition, results of Table 5 should be revised; there are high differences between COR and AOR, is this correct? For example, in the case of Age (25-29), 0.156 becomes in 5.889.

Response: Thank you for your insight comment and advise. We have modified and tried to describe these in the manuscript (p,14. Table 5)

Discussion:

Comment 1: Discussion should be start summarizing the main findings. Then, it should be follow the same order than results. The association between first aid training and knowledge was the last result reported, but it the first result discussed. Please, be consistent in this regard.

Response: Thank you for your guidance in comment. We have tried to correct based on comments accordingly.

Comment 2: Again, the manuscript cited from China has no reference (l.237-238).

Response: We corrected it (p,15. Line 316)

Comment 3: L.238-239: It does not understand the following sentence: “But a study finding in Egypt was higher than our finding where majority of teachers were knowledgeable towards first aid management of chocking”

Response: It is to mean that teachers in Egypt were more knowledgeable compared with this finding. (p,15. Line 304-306).

Comment 4: Discussion should address how to achieve that KG teachers train in first aid matters as choking management; for example, including this contents in university degrees, which was recommended in previous publications

Response: Thank you your comment and advice. We incorporate it in the manuscript in the discussion and recommendation part as first aid training to be included in the teachers’ educational curriculum.(p,16. Line 344-346)

Comment 5: The following references should be to take into account to complement the introduction and the discussion:

https://doi.org/doi:10.1016/j.anpede.2018.10.013

https://doi.org/10.1097/EJA.0000000000001272

https://doi.org/10.1007/s00431-021-03971-x

https://doi.org/10.1016/j.resuscitation.2020.04.021

https://doi.org/10.1016/j.anpede.2019.10.005

Response: Thank you for suggesting us to use references. We have used these articles both in the introduction and discussion part in the manuscript. We greatly appreciate all reviewers’ thoughtful review and recommendations in the manuscript.

Response: We have registered with PACE and the figures meets PLOS requirements. We downloaded from the PACE and uploaded as Figure 1.

Additional clarifications

In addition to the above comments, spelling and grammatical errors pointed out by the reviewers have been tried to correct.

We look forward to hear from you in due time regarding our submission and to respond to any further questions and comments you may have.

Sincerely,

Andualem Wubetie Aniley _____________

27/06/2021.

PLoS One. doi: 10.1371/journal.pone.0255331.r005

Decision Letter 2

Sergio García López

7 Jul 2021

PONE-D-20-32556R2

PLOS ONE

Dear Dr. Mr Andualem Wubetie

Please submit your revised manuscript by 11/07/2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Sergio García López, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments (if provided):

I thank the authors for the effort they have made with the changes to the manuscript.

They have improved the previous version. However, the considerations of a reviewer remain unaddressed. They have not incorporated the quotes that you have delicately and professionally suggested. In an area where there is little scientific evidence, attention must be paid to the work carried out that is in line with the one presented. It is essential that the authors incorporate them. If not, the reason for not joining must be justified. They should understand that reviewers carefully try to improve their manuscript for international reference. This gives your work a higher quality and gives the magazine added value. Based on the above, I suggest that you be careful and incorporate the quotes

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2021 Jul 30;16(7):e0255331. doi: 10.1371/journal.pone.0255331.r006

Author response to Decision Letter 2

11 Jul 2021

To Editors

Thank you again for giving me the opportunity to submit a revised draft of my manuscript titled - knowledge, attitude, and practice on first aid management of choking and associated factors among kindergarten teachers in Addis Ababa Governmental Schools, Addis Ababa, Ethiopia to PLOS ONE. I appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on my manuscript. I am grateful to the reviewers for their insightful comments on my paper. I have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. I have highlighted in blue the changes within the manuscript. I hope it will now be suitable for publication in the PLOS ONE.

With regards

Andualem Wubetie, MSc

Here is a point-by-point response to the reviewers’ comments and concerns.

Comments from the editor

PLOS ONE

Journal Requirements:

Response: Thank you for your insight and constructive comment to correct these comments. We have reviewed all references and corrected accordingly.

We corrected papers that have been listed in the reference but incorrectly cited in the manuscript. Correctly cited papers are reference 15,16,17. (p-4, line 83)

We have removed papers that are not recent and considering as not much relevant and replaced with current papers according to your suggested comments and reviewers’

Removed papers are.

(American Academy of Pediatrics, Committee on School Health. Guidelines for emergency medical care in school. Pediatrics. 2001;107:435– 436.

Altayehu M. Assessment of General approach for appropriate pediatric first aid and associated factors among primary school teachers in Addis Ababa,Ethiopia; 2015. 2015;1–55.

Meral Bayat MB. Evaluating First-aid Knowledge and Attitudes of a Sample of Turkish Primary School Teachers. 2007 Oct 1;33(5):428–32.)

Additional comments

Additional Editor Comments (if provided):

I thank the authors for the effort they have made with the changes to the manuscript.

Response:

Thank you also for the comments. We tried to incorporate the comments in the manuscript.

To Reviewers