Effectiveness of First Aid training: Engaging community stake holders in rural India.

Introduction

First aid is defined as the assessments and interventions that can be performed by a standard immediately with minimal or no medical equipments.1 It helps in preserving lives, preventing further harm, promoting recovery. Often the first action taken for management of injuries and common illness decides the future course of disease and complication rates. A first aid provider is defined as someone with formal training in first aid, emergency care, or medicine who provides first aid.¹ Laypersons play an important factor for saving lives in emergency situations. One important barrier and main concern of laypersons about giving first aid to acute ill or injured people is the fear to make mistakes.² In Austria 68% of the participants of a study (n=597) stated that they would not provide first aid because they feared to do something wrong³ .Training in first aid will help in alleviating the fear in them. Several studies have shown a clear relationship between the level of first aid training and the quality of first aid measures provided.^3-5 But in countries like India various incorrect practices and myths still exist regarding injuries and illnesses.⁶ These might do more harm to the patient than good. So the people are in need of a quality education on first aid. This underlines the importance of first aid training for the public.

In India Accredited Social Health Activists (ASHAs) are health workers designated to each village under National Rural Health Mission (NRHM). They play key role in delivering the health care, at the village level.⁷ They have made significant contribution in their respective community to increase the level of health awareness, promotion of institutional delivery, immunization coverage and other health related activities.8 In conditions where treatment has to be given at first contact like first aid, this health worker may be the only person available in village. They have the potential to do so, because of close contact with the community and the acceptance of her services by the community. So ASHA Health workers were the logical choice to include in the first aid training. When children are at school, they will be under the monitoring of teachers. While being so, minor injuries and other accidents do happen to them often. So the teachers will be in a better position to administer the first aid. Many of the procedures can be easily learnt and also applied even by a layman.⁵ Although school health programmes in India have been in existence since 1962, but limited emphasis on first aid exists in the educational curriculum.9 So the teachers formed the other group to whom the first aid was given in this study.

An educational intervention was carried out for a group of ASHA health workers and school teachers belonging to a gram panchayat which is the rural administrative unit, to assess their knowledge regarding providing first aid and also to evaluate effectiveness of our training. The effectiveness of training among ASHAs and teachers were also compared.

Material and Methods:

An interventional study was undertaken in gram panchayat called Uttanoor in Kolar district covering 10,000 population, involving eight ASHAs and fourteen teachers belonging to the gram panchayat. Eleven objective types of questions were formed. They were related to following: what is first aid, prior training in first aid and management of various common conditions which require first aid like, bleeding from the wound, fractures, epistaxis, head and spine injury, epilepsy, hypoglycaemia, dog bite, snake bite, burns and syncope. Later a lecture and demonstration was given related to first aid in the above mentioned situations. So the lesson plan was as given in table 1. Their doubts were clarified after the lecture on each situation. This was followed by a post test.

Statistical Analysis: Correct knowledge regarding first aid in each situation was assessed by calculating proportions. Correct answer for each question was given one marks and zero for wrong answer. Maximum score for each participant was ten. The mean scores of pre-test for each group were found out. The performance of the groups during the pre and post-test was analyzed using Mann Whitney U test. The change in knowledge overall and in individual ASHA and teachers group was assessed by comparing the pre and post test scores using Wilcoxon signed rank test.

Results:

Table 2 shows the distribution of participants. Majority of the participants were teachers of schools (63.63%) and the remaining were ASHA health workers (36.36%). Sixty two percent of ASHAs and 83% of teachers informed that they were never trained in first aid before.

Table 3 shows that most participants (90.9%) knew what was meant by the term first aid. All participants had correct knowledge regarding giving first aid for bleeding before training itself. Correct knowledge regarding first aid of most common ailments like epistaxis, epilepsy, head and neck injury, snake bite and syncope was very poor. Improvement in knowledge among all subjects after training was observed in first aid management of epilepsy, burns and epistaxis. Good improvement was observed in other conditions too except for hypoglycemia.

Table 4 shows the mean pre-test scores of the participants. The mean score of ASHA health workers was 3.38±1.59 and of teachers was 3.5±1.4. Mann Whitney U test was applied and no significant difference was found (p = 0.85) between mean pre-test scores of teachers and ASHA health workers.

Table 5 shows the post test scores of participants. The mean scores of ASHA health workers were 8±0.5 and that of teachers was 7.64±1.15. Mann Whitney U test showed no difference in post test scores between ASHA health workers and teachers (p=0.42)

Table 6 shows the comparison of pre-test and post test scores among teachers and ASHA health workers. Mean pre test scores was 3.45±1.43 which was increased to 7.77±0.97 after intervention and this difference was found to be statistically significant (p<0.001). There was significant improvement observed in Teachers and health worker group too.

Discussion:

First aid delivery is an essential knowledge which can be acquired even by a layperson. Health workers under the national program were supposed to acquire the same under their training programme.⁷ Even teachers are expected to have a basic knowledge in first aid delivery. Surprisingly only 38% of health workers and 17% of teachers were trained in first aid courses before. It was evident by their pre test scores too, the mean scores of both the groups being closer to one third. It is observed in a study done by Goel and Singh that the knowledge regarding first aid is poor among school children and it is also associated with various incorrect practices and myths related to illnesses and injuries.⁶ Incorrect practices may even cause more harm than help to the person injured.

The study demonstrated that health education was effective among teachers in improving their knowledge regarding first aid. In the United States more than 20 million children suffer injuries every year of which four million occur at school.¹⁰ ‘Safety makes sense’-a study conducted in New York City showed that the first aid course was effective in training teachers and students.¹¹ Because of the magnitude of problem, injury control programs must complement injury prevention programs. Only some good schools have the luxury of having a fulltime school nurse as staff. Thus, it falls upon teachers and other support personnel to be the primary providers of first aid, especially since school injuries often occur in their presence.¹² In developing counties like India, because of low socio-economic status, inadequate transport facilities and improper health care delivery it must be mandatory to train all teachers in first aid. It was noted in this study that health education improved knowledge regarding first aid among health workers too. Health workers were as efficient as teachers in understanding about first aid.

Even though the teachers had higher educational status; the post test scores of health worker were higher. But it wasn’t statistically significant. It is demonstrated in other studies that training was effective in improving the knowledge regarding various health related conditions like asthma, hypertension, diabetes, cancer, immunization, maternal and child health, nutrition, tuberculosis, and HIV and AIDS.^13-17 Prevalence of injuries is common in general population, hence it is essential to train community health workers in first aid. One of the most important features of programs that engage health workers is that these people strengthen already existing ties with community networks. This is not surprising, since they are uniquely qualified as connectors to the community because they generally live in the communities where they work and understand the social context of community.^18,19

Other studies have demonstrated that improvement in first aid knowledge after training did not increase the rate of helping.⁴ Therefore the motivation to help others is paramount and the helping rate can probably be increased by first aid courses that include strategies to overcome inhibitors of emergency helping behaviour.⁴ Learning first aid should therefore include both knowledge-transfer and motivation to give first aid.5 We think that teaching first aid has led to positive changes in social responsibility and empathic behaviour. Health workers are the cornerstone of various countries national health programmes to strengthen the healthcare delivery system with a focus on the needs of the poor and vulnerable sections among the rural population. Hence it is essential to investigate the methods to improve health workers performance, especially through the process of training. Both the quality and quantity of training in first aid will improve the performance of teachers and health workers. This study is an example for improvement in health by community participation. At the end of training all the participants were provided with first aid kit which was purchased by the untied funds provided under the national programme. Every small administrative unit like Panchayat should come forward and train their health workers and teachers in first aid. Retraining has to be done to update their knowledge and to motivate them in practicing first aid.

Conclusions:

There is lack of knowledge regarding first aid in both teachers and community health workers. But both are receptive to new knowledge regarding the same. So there is a need for giving quality training to health workers and teachers all over regarding delivery of first aid, so that they can save lives when situation demands.

Conflict of interest: Nil.

The funding source: No financial assistance taken for the study