research study on first aid among students

Assessment of the Knowledge Level of First Aid among Medical Students in Work Environment

Affiliations.

• 1 College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia.
• 2 King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
• 3 Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
• 4 Collage of Nursing, Minoufia University, Shibin Al Kawm, Egypt.
• PMID: 35677854
• PMCID: PMC9170404
• DOI: 10.1155/2022/8381819

First aid is one of the most important life-saving skills a health provider specifically or anybody generally must have. It can be defined as the first treatment one provides at the site of the accident to the injured person until full medical treatment is available. In some emergency situations, simple first aid can make a life-or-death difference. Aim . This study is designed to evaluate the knowledge of first aid among medical students at KSAU-HS in Riyadh, Saudi Arabia. Methods . The cross-sectional study is conducted in KSAU-HS, Riyadh, about the knowledge of first aid among medical students. A self-administered structured questionnaire is used for the purpose of data collection. The main variables are as follows: to compare the knowledge of first aid between male and female medical students, among different years of study, and identify the percentage that have knowledge of first aid. Results . Out of 326 students, 10 students (3.1%) scored excellent, 99 (30.4%) good, 136 (41.7%) average, 75 (23%) poor, and 6 (1.8%) very poor. Conclusion . The level of knowledge improved with the advancement in years, but this was not sufficient, and more training should be given to all medical students on first aid.

Copyright © 2022 Asma Alanazi et al.

Publication types

• Retracted Publication
• Cross-Sectional Studies
• Health Knowledge, Attitudes, Practice
• Students, Medical*
• Surveys and Questionnaires

• Open access
• Published: 21 June 2021

Determinants of knowledge, attitude, and practice towards first aid among kindergarten and elementary school teachers in Gondar city, Northwest Ethiopia

• Belayneh Shetie Workneh 1 ,
• Enyew Getaneh Mekonen 2 &
• Mohammed Seid Ali 3  

BMC Emergency Medicine volume  21 , Article number:  73 ( 2021 ) Cite this article

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Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. School-age children are more likely to experience unintentional injuries in the school, while they are playing and teachers are the primarily responsible body for keeping the welfare of the students. Knowing the knowledge, attitude, and practice of kindergarten and elementary school teachers towards first aid will be used as an input for policymakers to intervene and provide training. Therefore, this study was aimed to assess knowledge, attitude, practice, and associated factors towards first aid among kindergarten and elementary school teachers in Gondar city, Northwest Ethiopia, 2021.

An institution-based cross-sectional study was conducted from January 01 to 20, 2021. A simple random sampling technique was employed to recruit 346 participants. A structured pretested self-administered questionnaire was used to collect data. Data were entered in Epi-info version 7, analyzed using SPSS version 21, and presented by frequencies, percentages, tables, and graphs. Bivariable relationships between the independent and outcome variable were investigated using a binary logistic regression model and a multivariable analysis was run to control potential confounding factors. Variables with a p -value < 0.05 were considered as factors significantly associated and the strength of association was determined using an odds ratio with a 95% CI.

Only 41.1% of the teachers had good knowledge of first aid. Nearly two-thirds (64.8%) of the teachers had a favorable attitude towards first aid. The majority (85.8%) of the teachers who faced a child in need of first aid in their school gave first aid. Factors like working experience [AOR: 2.45; 95% CI (1.26, 4.73)], school level [AOR: 4.72; 95% CI (1.96, 11.4)], school type [AOR: 4.23; 95% CI (2.07, 8.64)], and having information about first aid [AOR: 2.09; 95% CI (1.11, 3.92)] were significantly associated with knowledge. School-level [AOR = 5.4, 95% CI (2.18–11.67)], school type [AOR = 0.45, 95% CI (0.21–0.94)], and working experience [AOR = 0.33, 95% CI (0.13–0.86)] were the factors significantly associated with attitude.

Less than half and nearly two-thirds of the teachers had good knowledge and a favorable attitude towards first aid. The majority of the teachers who encountered a child in need of first aid gave first aid. Having higher working experience, working in elementary and private schools, and having previous information increases the odds of having good knowledge. Teachers who work in elementary and private schools and have the lower working experience had higher odds of favorable attitude towards first aid. It is better to give attention to the training of staff on first aid specifically for teachers working in kindergarten and governmental schools and new employees and consider integrating first aid in teachers’ training curriculum.

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First aid can be defined as the immediate care given to a person who has been injured or suddenly ill with materials available on hand to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery [ 1 , 2 , 3 ]. It is one of the most important procedures to follow in case of a medical emergency or an accident. At least 39% of pre-hospital deaths are potentially preventable with better interventions [ 4 ]. An accident is something harmful and takes place suddenly and unexpectedly that may result in simple injuries or major complications like broken bones with heavy bleeding, failure to breathe, unconsciousness, or even death [ 5 ]. Many dangerous situations like fainting, falls, intoxications and road crashes that happen at home, school, or in the workplace affect victims and their relatives both physically and psychologically [ 3 ].

Unintentional injuries are the leading cause of morbidity and mortality for children [ 6 ]. Injuries continue to be an important cause of morbidity and mortality in the developed and developing world [ 7 ]. Globally more than 2000 families lost their child due to unintentional injury or accidents every day [ 5 ]. The most common causes of accidents and injuries in school children are bullying and assaults, slip and fall accidents, school bus, and playground accidents, food poisoning, and sports activities which result in a significant number of serious injuries [ 8 ]. Negligence in injuries or accidents at elementary and kindergarten schools causes the life-threatening condition [ 9 ]. The majority of injuries are occurred during free play and on the playground and are precipitated by child-related factors, like being pushed. Boys had significantly higher median injury rates than girls [ 10 ].

In Ethiopia, the annual mortality caused by injuries is projected to increase from 10,697 in 2015 to 11,989 by 2030 among children less than 5 years and the number of deaths among 0–14-year olds will be 30,364 [ 11 ]. School-age children are more likely to experience unintentional injuries in school, while they are playing. School teachers are the primarily responsible body for keeping the welfare of the students and oversee their activities. They are the first contact and responsible person when children faced injuries. However, studies showed that the level of knowledge and basic practice of first aid among school teachers were found to be poor [ 12 , 13 , 14 ].

A study conducted at Lideta sub-city, Addis Ababa and Jimma, Ethiopia among kindergarten teachers, showed that 79.9 and 50.4% of the teachers encountered a child in need of first aid, and 89.7 and 52.1% of teachers gave first aid respectively [ 13 , 14 ]. In the country, schools have not Emergency Medical Technician (EMT), paramedics, or other trained health professionals who will give first aid. However, pre-hospital school-based Emergency Medical Service (EMS) at school by school personnel is mandatory for saving the children from disability and death. Therefore, assessing the level of knowledge, attitude, and practice of kindergarten and elementary school teachers on first aid is important to intervene and provide training.

Methods and materials

Study design and period.

An institution-based cross-sectional study was conducted from January 01 to 20, 2021.

Study setting

The study was conducted at kindergarten and elementary schools found in Gondar city, Northwest Ethiopia. Gondar city is 727 Km far from Addis Ababa, the capital city of Ethiopia, and 180 km from Bahir Dar, the capital city of Amhara regional state. Gondar city has a total area of 192.3 sq. KM. The city has a total population of 338, 646 peoples with 256,041 people whose age is between 18 and 65 years old in 6 sub-cities and 27 Kebele with a total of 78,772 households. Under the Gondar city administration education office there are 11 secondary, 64 elementary, and 70 kindergarten schools with a total of 2649 teachers.

Study participants

All kindergarten and elementary school teachers working in Gondar city who were available during the data collection period were included in the study. Those teachers who are seriously ill and attending external training courses off-site during the study period were excluded from the study.

Sample size determination

The sample size was calculated using the single population proportion formula by taking the estimated proportion of knowledge, attitude, and practice among kindergarten and elementary school teachers: 44% [ 13 ], a confidence level of 95%, and a margin of error of 5%. The final sample size was 346 after using a correction formula and adding a 10% non-response rate.

Sampling technique and procedure

A simple random sampling technique was employed to recruit the required participants for the study. First, we stratified participants into elementary and kindergarten school teachers, and then we allocated the required sample for each stratum proportionally. Finally, study participants were selected from each stratum by simple random sampling.

Data collection instruments and procedures

Data were collected using a structured pre-tested self-administered questionnaire. The questionnaire contains 43 questions arranged into four sections; the first section contains eight questions regarding the socio-demographic characteristics of the participants, the second section contains 11 questions regarding first aid knowledge of kindergarten and elementary school teachers, the third section contains seven attitude related questions, and the last section contains 17 practice-related questions. The questionnaire was adapted from a similar study done at Addis Ababa, Ethiopia [ 14 ]. Data were collected with the help of four trained BSc nurse data collectors and two MSc nurse supervisors. A written guideline was given to the data collectors to assure that every participant received the same directions and information. The anonymity of the participant was kept by informing them not to write their name. The instruments were distributed among the study population, after guarantying their willingness to take part in the study, and then it was collected by the data collectors after completion. During data collection data collectors and supervisors followed the recommended precautions to prevent COVID-19.

Data processing and analysis

Data clean-up and cross-checking were done before analysis. Checked, cleaned, and coded data were entered into EPI info version 7 and exported to SPSS version 21 for analysis. Descriptive statistics like frequencies, percentages, mean and standard deviation, tables, and figures were used to present data. Bivariable relationships between each independent variable and outcome variable were investigated using a binary logistic regression model. Those independent variables with a p -value < 0.2 at the bivariable level were included in multivariable analysis to control potential confounding factors. After adjusting their effect on the outcome variable, those variables with a p -value < 0.05 with a 95% confidence interval were regarded as factors significantly associated.

Data quality assurance

The data collection tool was pretested before the actual data collection time at Bahir Dar city kindergarten and elementary schools, which were not included in the study using 5% of the total sample size. Amendments on the instrument, such as unclear questions and ambiguous words were made accordingly. The pretest was also used to estimate how much time it takes to administer the entire questionnaire. The tool was first developed in the English language and translated to the Amharic language with back translation to English for consistency. The one-day training was given to data collectors and supervisors on the objective of the study, instrument, and data collection procedures by the principal investigators. Supervision was conducted by the principal investigators and supervisors. To ensure data quality, each data collector checked the questionnaire from each study participant for completeness daily. The supervisors and principal investigators reviewed each questionnaire daily and checked for completeness.

Socio-demographic characteristics of the respondents

A total of 338 respondents have participated in the study with a 97.7% response rate. Among the total participants, 212 (62.7%) respondents were females. One-third (33.4%) of the respondents were in the age group of above 42 years. Of the total participants, 219 (64.8%) respondents were degree holders. Two hundred thirteen (67.5%) of the respondents were married. Among the total respondents, 103 (30.5%) respondents had greater than 10 years of work experience in teaching. The majority (84.9%) of the respondents were from primary schools and 266 (77.8%) of the respondents were from government schools. Most (71.6%) of the respondents did not take the training in first aid (Table  1 ).

Knowledge of kindergarten and elementary school teachers towards first aid

Of the total respondents, only 41.1% (with 95% CI (35.9, 45.7%)) of the respondents had good knowledge of first aid (Fig.  1 ). The majority (81.7%) of the participants had information about first aid. Of these, 10.9, 7.6, 21.0, and 60.5% were heard from family, books, media, and health professionals respectively. The majority (93.5%) of the respondents correctly respond to what first aid means. Nearly two-thirds (66.3%) of the participants were aware of giving nothing by mouth for fainting children. More than three fourth (79.6%) of the respondents understand the concept of immobilization for neck and back injuries (Table  2 ).

Knowledge and attitude of kindergarten and elementary schools teachers towards first aid in Gondar city, Northwest Ethiopia, 2021 ( n  = 338)

The attitude of kindergarten and elementary school teachers towards first aid

Among the total participants, nearly two-thirds (64.8%) with 95% CI (59.2–69.8%) of the respondents had a favorable attitude towards first aid (Fig.  1 ). About 200 (59.2%) of the respondents strongly agreed with the idea giving first aid at school is fair. One hundred three (30.5%) of the respondents were strongly disagreed with giving first aid at school is unpleasant. About half (49.4%) of the respondents were strongly disagreed with giving first aid is not good. About 207 (61.2%) of the respondents were strongly agreed with giving special care for injured children in academic work is appropriate (Table  3 ).

The practice of kindergarten and elementary school teachers towards first aid

More than three-fourths (76.9%) of the teachers faced a child in need of first aid in their school and 85.8% of them gave first aid for the child. Ninety-five (28.1%) of the participants faced a child with difficulty of breathing and nearly half (49.5%) of them encouraged the student to sit quietly. One hundred forty-six (43.2%) of the respondents faced a child with fainting and 75.3% of them kept the student in a flat position. Nearly three-fourths (74.9%) of the teachers faced a child with bleeding from his/her nose and more than half (51.0%) of them applied uninterrupted pressure by pressing nostrils together. Nearly half (50.6%) of the participants faced a child with bleeding on his/her body and 35.1% of them pressed firmly with a clean bandage to stop bleeding. One hundred forty-eight (43.8%) of the teachers faced a child with seizure/epilepsy and 41.2% of them moved surrounding objects to avoid injury. Nearly one-third of the respondents faced a child with choking and more than half (58.3%) of them stood behind the child encircling the child’s chest by hands and squeezed. Nearly one-fifth (19.5%) of the participants faced a child with an injured neck and back and more than half (54.6%) of them avoided head and neck movement and kept their body straight (Table  4 ).

Factors associated with knowledge of teachers towards first aid

Using bivariable logistic regression analysis age, experience, school level, school type, training, having information about first aid, and history of exposure with a child in need of first aid were found to be significantly associated with knowledge. In multivariable logistic regression analysis, working experience, school level, school type, and having information about first aid were significantly associated with the knowledge of teachers towards first aid.

Teachers who worked for 11–20 years were nearly three times higher to be knowledgeable compared with teachers who worked for less than 10 years [AOR: 2.45; 95% CI (1.26, 4.73)]. Those teachers working at elementary schools were nearly five times higher to have good knowledge compared with teachers working at kindergarten schools [AOR: 4.72; 95% CI (1.96, 11.4)]. Those study participants who work at private schools were nearly four times higher to have good knowledge about first aid compared with governmental school teachers [AOR: 4.23; 95% CI (2.07, 8.64)]. Those teachers who had information about first aid were two times higher to have good knowledge compared with their counterparts [AOR: 2.09; 95% CI (1.11, 3.92)] (Table  5 ).

Factors associated with the attitude of teachers towards first aid

Bivariable and multivariable logistic regression analyses were carried out. Age, training, school level, school type, and experience were eligible for multivariable analysis. In multivariable analysis, the factors significantly associated with the attitude of the participants were; school level, school type, and experience. Teachers who work in elementary schools were five times more likely to have a favorable attitude towards first aid than teachers who work in kindergarten [AOR = 5.4, 95% CI (2.18–11.67)]. Teachers who work in governmental schools were 55% times less likely to have a favorable attitude towards first aid than teachers who work in private schools [AOR = 0.45, 95% CI (0.21–0.94)]. Teachers who work for greater than equal to 21 years were 67% times less likely to have a favorable attitude towards first aid than teachers who work for ten and below 10 years [AOR = 0.33, 95% CI (0.13–0.86)] (Table  6 ).

The result of this study revealed that only 41.1% of the respondents have good knowledge of first aid. The finding of this study is in line with previous studies conducted in Addis Ababa, 40.0% [ 14 ], Debretabor, 45.8% [ 12 ], and Jimma, Ethiopia 44.4% [ 13 ]. According to the participant’s response, 85.8% of the respondents report as they give first aid for injuries and illness however less than half of the participants have good knowledge. It implies that some of the teachers exercise first aid interventions without basic knowledge. It shall be given attention and first aid training to equip school teachers with first aid knowledge to give evidence-based first aid for accidents.

The finding of this study was higher than a study conducted in Saudi Khamis mushyt city, 19.6% [ 15 ]. The difference might be due to variation in sample size and socio-demographic characteristics of the respondents. On the other hand, the result of this study was lower than the studies conducted in Malaysia 77.4% [ 16 ] and Iraq 95% [ 17 ]. The possible reason for this variation might be due to differences in a school setup, socio-demographic characteristics of the respondents, and variation in the measurement. The previous studies were conducted among elementary school teachers whereas the current study was conducted among both elementary and kindergarten school teachers.

This study revealed that 64.8% of kindergarten and elementary school teachers had a favorable attitude towards first aid. This finding was in line with a study conducted in Saud Arabia (67%) [ 18 ] and Riyadh (68.4%) [ 19 ]. This might be due to the similarities of teachers in academic activities in the school. However, this finding was lower than studies conducted in Debre tabor, Ethiopia (75%) [ 12 ], Addis Ababa, Ethiopia (75%) [ 14 ], and Jatinangor (71.5%) [ 20 ]. This discrepancy might be due to the variation of teacher’s academic performance, knowledge, training about first aid, and the school settings across those areas. The previous study conducted in Debre tabor was conducted only among elementary school teachers and the study in Addis Ababa, Ethiopia was conducted among kindergarten school teachers only. On the other hand, our study incorporates the attitude of both elementary and kindergarten school teachers.

In the current study, 85.8% of the teachers who encountered children in need of first aid gave first aid to the child. This finding was relatively consistent with a study conducted in Addis Ababa, Ethiopia (89.7%) [ 14 ]. However, it was higher than studies conducted in Debre Tabor, Ethiopia (64%), Jimma, Ethiopia (52.1%), Khamis Mushayt City, Saudi Arabia (54.9%), and Indonesia (78.8%) [ 12 , 13 , 15 , 20 ]. The possible justification for this difference might be due to the difference in data collection tool used in each study, study participants, and knowledge level. The current study was conducted among kindergarten and elementary school teachers whereas the previous studies were conducted among either kindergarten or elementary school teachers only.

Working experience, school level, school type, and having information about first aid were significantly associated with knowledge towards first aid. The odds of having good knowledge were nearly three times higher among teachers who had 11–20 years of experience compared with those teachers who had less than 10 years of experience. This finding was supported by studies conducted in Debre tabor, Ethiopia, Addis Ababa, Nigeria, Malaysia, Al-Qassim Saudi Arabia, and Khamis Mushyt city Saudi Arabia [ 12 , 14 , 15 , 16 , 21 , 22 ]. This might be due to learning from experience as they faced individuals in need of first aid, training on first aid, and pre-hospital service. The finding of this study revealed that special consideration should be given to the newly employed teachers. This might also be due to as teacher’s working experience increases their academic studies will be complemented by another way of learning from day-to-day exposure. In turn, previous exposure of a child in need of first aid also provides them with crucial knowledge, skills, and personal attributes through communication, team-working and problem-solving skills.

The odds of having good knowledge were five times higher among elementary school teachers compared with kindergarten school teachers. It might be due to the difference in the level of education. According to the result of this study, almost all of the elementary school teachers were diploma and degree holders while kindergarten school teachers were certificate. This implies that special attention should be given to kindergarten school teachers since they give care for kids who didn’t aware of their environment and susceptible to accidents. Private school teachers were four times higher to be knowledgeable compared with teachers who work at governmental schools. This might be due to the difference in a school setup. Most of the time private schools are business-oriented, competitive, and well equipped with infrastructures including first aid kits. To attract customers and to be competitive private schools might provide training for teachers about first aid and accident prevention which makes private school teachers more knowledgeable compared with governmental school teachers.

Similarly, Participants who had previous information about first aid were two times higher to be knowledgeable compared with their counterparts. This finding is supported by studies conducted in Addis Ababa [ 20 ] and Debretabor, Ethiopia [ 12 ]. This might be due to having previous information regarding first aid leads to a higher score of knowledge-related questions than respondents who didn’t have information about the issue. This implies that obtaining information about first aid and emergency medical care either from media, training, health professionals, or family increases the acquisition of knowledge towards first aid.

School-level, school type, and working experience were significantly associated with the attitude towards first aid. Teachers who work in elementary schools were five times more likely to have a favorable attitude towards first aid compared with teachers who work in kindergarten schools. This might be due to those teachers who work in primary schools were more knowledgeable about first aid since the school level determines the teacher’s competency. Governmental school teachers were 55% times less likely to have a favorable attitude towards first aid than teachers who work in private schools. This might be due to private schools might have good standards and structures of the school including first aid kits and their teachers also might have strict control since private schools are business-oriented. Similarly, the working experience was significantly associated with the attitude of teachers towards first aid. Teachers who had working experience of greater than or equal to 21 years were 67% times less likely to have a favorable attitude compared with teachers who had working experience of less than or equal to 10 years. This finding was supported by other studies [ 14 , 23 ], [ 24 ]. This might be due to those teachers with long time experience give less attention to first aid because mostly they are old age and their academic status is diploma whereas younger age groups of teachers were degree holders.

This study has some limitations

There might be a possibility of social desirability and recall bias. We were unable to identify factors associated with practice due to the variation in the type of cases requiring first aid. The generalizability of the findings to schools in other parts of the country might be compromised since the study was conducted in one city. We were also unable to make an adequate comparison with other studies due to the lack of similar studies.

Less than half and nearly two-thirds of the teachers had good knowledge and a favorable attitude towards first aid. The majority of the teachers who encountered a child in need of first aid gave first aid. Having higher working experience, working in elementary and private schools, and having previous information about first aid increases the odds of having good knowledge of first aid. Teachers who work in elementary and private schools and have the lower working experience had higher odds of favorable attitude towards first aid. It is better to give attention to the training of staff on first aid specifically for teachers working in kindergarten and governmental schools and new employees. Policymakers in education might use the finding of this study as an input to integrate first aid in teachers’ training curriculum.

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Abbreviations

Adjusted odds ratio

Confidence interval

Emergency medical service

Emergency medical technician

Statistical package for social sciences

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Acknowledgments

The authors are grateful to the University of Gondar, Gondar city administration Education Office, data collectors, and study participants.

No funding has been received for the conduct of this study and/or preparation of this manuscript.

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Department of Emergency and Critical Care Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Belayneh Shetie Workneh

Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Enyew Getaneh Mekonen

Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Mohammed Seid Ali

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Contributions

BSW: participate in the conception and design; analysis and interpretation of data; drafting and revising the manuscript. EGM: took part in the acquisition, analysis, and interpretation of data; drafting the article or revising it critically for important intellectual content; drafting and revising the manuscript. MSA: participate in the analysis and interpretation of data, drafting the manuscript, and revising it. All authors agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

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Correspondence to Enyew Getaneh Mekonen .

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Workneh, B.S., Mekonen, E.G. & Ali, M.S. Determinants of knowledge, attitude, and practice towards first aid among kindergarten and elementary school teachers in Gondar city, Northwest Ethiopia. BMC Emerg Med 21 , 73 (2021). https://doi.org/10.1186/s12873-021-00468-6

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The willingness to perform first aid among high school students and associated factors in Hue, Vietnam

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Health Personnel Training Institute, University of Medicine and Pharmacy, Hue University, Hue, Vietnam, School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan

Roles Formal analysis, Funding acquisition, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing

Affiliations Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America, Department of Physiology, Hanoi Medical University, Hanoi, Vietnam, Research Advancement Consortium in Health, Hanoi, Vietnam

Roles Data curation, Investigation, Project administration, Writing – review & editing

Affiliation Daklak Center for Diseases Control and Prevention, Daklak, Vietnam

Roles Investigation, Writing – review & editing

Affiliation University of Medicine and Pharmacy, Hue University, Hue, Vietnam

Roles Conceptualization, Investigation, Supervision, Writing – review & editing

Affiliation Faculty of Public Health, Department of Epidemiology and Statistics, Danang University of Medical Technology and Pharmacy, Da Nang, Vietnam

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Writing – review & editing

Affiliation Department of Obstetrics and Gynecology, University of Medicine and Pharmacy, Hue University, Hue, Vietnam

Roles Conceptualization, Funding acquisition, Methodology, Resources, Supervision, Writing – review & editing

Affiliations Faculty of Nursing, University of Medicine and Pharmacy, Hue University, Hue, Vietnam, Faculty of International Education, University of Medicine and Pharmacy, Hue University, Hue, Vietnam, Office of Science-Technology and International Relations, University of Medicine and Pharmacy, Hue University, Hue, Vietnam

Roles Formal analysis, Software

Affiliation Institute of Gastroenterology and Hepatology, Hanoi, Vietnam

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Software, Supervision, Writing – original draft, Writing – review & editing

Affiliations Research Advancement Consortium in Health, Hanoi, Vietnam, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America

• Le Duc Huy, 
• Pham Thanh Tung, 
• Le Nguyen Quynh Nhu, 
• Nguyen Tuan Linh, 
• Dinh Thanh Tra, 
• Nguyen Vu Phuong Thao, 
• Tran Xuan Tien, 
• Hoang Huu Hai, 
• Vo Van Khoa, 

• Published: July 27, 2022
• https://doi.org/10.1371/journal.pone.0271567
• Reader Comments

Adolescents who are willing to perform first aid can help prevent injuries and ultimately death among themselves and others involved in accidents or injuries. This study aims to estimate the prevalence of students’ willingness to perform first aid procedures and additionally examine associated factors among high school students in Hue, Vietnam.

A cross-sectional study utilizing multi-stage stratified random sampling was conducted between April to July 2020 by investigating 798 high school students in Hue, Vietnam. Participants were invited to complete a self-reported questionnaire pertaining to individual demographic characteristics, personal perception of self-efficacy, and willingness to perform first aid. To better interpret these findings, both multivariable linear and Poisson regression models were fitted to evaluate the association between individual student characteristics and the willingness to perform first aid.

The prevalence of having willingness to perform first aid (defined as ≥4 points out of 5 to all three questions) was 49.9% (95%CI:28.6–71.2%). The major reported barriers in performing first aid were fear of making mistakes and hurting victims (34.4%, 95%CI:31.9–37.0%), no prior first aid training (29.8%, 95%CI:25.9–33.9%), and forgetting first aid steps (23.0%, 95%CI:15.8–32.2%). By employing the multivariable linear regression model, it was identified that students with high (β = 0.614, 95%CI:0.009–1.219) or very high (β = 1.64, 95%CI:0.857–2.422) levels of self-efficacy appeared to be more willing to perform first aid. Similarly, in the Poisson regression models, compared to neutral students, students who reported high (PR = 1.214, 95%CI:1.048–1.407) or very high (PR = 1.871, 95%CI:1.049–3.337) levels of self-efficacy were more willing to perform first aid.

Conclusions

The level of willingness to perform first aid among high school students in this study population was found to be moderate. Therefore, integrating activities to promote self-efficacy in first aid training could be considered a progressive step towards improving a student’s willingness to provide such life-saving procedures.

Citation: Huy LD, Tung PT, Nhu LNQ, Linh NT, Tra DT, Thao NVP, et al. (2022) The willingness to perform first aid among high school students and associated factors in Hue, Vietnam. PLoS ONE 17(7): e0271567. https://doi.org/10.1371/journal.pone.0271567

Editor: Venkat Rao Vishnumolakala, Curtin University, AUSTRALIA

Received: October 8, 2021; Accepted: July 3, 2022; Published: July 27, 2022

Copyright: © 2022 Huy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: According to our application to the Institutional Ethics Committee of Hue University of Medicine and Pharmacy, the data cannot be shared publicly because of ethical restrictions to protect the confidentiality of the participants. A deidentified dataset is available for researchers who meet the criteria for access to confidential data. Requests for data should be submitted to the Institutional Ethics Committee of Hue University of Medicine and Pharmacy (Email: [email protected] ; Add: 06 Ngo Quyen St., Hue 530000 – Vietnam; Tel: +84.234.3822873) and the corresponding author, Dr. Le Duc Huy (contact via [email protected] ).

Funding: The study received funding (for study design and data acquisition) from the Research Advancement Consortium in Health (REACH) - a non-profit entity in Vietnam, of which Linh Bui and Tung Pham are co-managers. Linh Bui and Tung Pham did not receive any payment or compensation from this position at REACH. On behalf of REACH, they provided consultancy on study design, data collection and analysis, and preparation of the manuscript. However, Linh Bui and Tung Pham had no role in the decision to publish this study, and this final decision belongs to the funded research team.

Competing interests: The authors have declared that no competing interests exist.

1. Introduction

Child and adolescent injuries are a significant cause of childhood mortality globally, leading to a large burden upon public health in low- and middle-income countries (LMICs) [ 1 , 2 ]. According to a study investigating the global burden of diseases in 2017, it was found that injuries are a major factor that is attributed to approximately 1900 child death cases per day worldwide [ 3 ]. Recent studies demonstrated that various first-aid interventions such as cardiopulmonary resuscitation (CPR), management of a suspected spinal/head injury or bleeding that is performed by untrained personnel (e.g., caregiver, bystander) or a trained provider could be crucial to mitigate mortality and the risk of disability caused by injuries [ 4 ]. Additionally, training children in first aid techniques has been considered a novel strategy to increase the rate of CPR within a community, thus resulting in higher survival rates [ 5 – 7 ]. A high level of willingness to perform first aid among adolescent bystanders can improve the timely access to quality care for victims, contributing to the reduction of morbidity and mortality caused by injuries [ 5 , 8 ]. Therefore, the World Health Organization has recommended the “Kids save lives” statement to emphasize the role of children in increasing the rate of CPR amongst lay people [ 8 , 9 ]. While studies of children receiving first aid training have been well documented in developed countries [ 10 , 11 ], the data in developing countries remains limited and presently illustrates a low rate of first aid training for children [ 12 , 13 ]. Regardless, even among children who received first-aid training, their willingness to perform first aid was influenced by various factors. Furthermore, several studies have indicated that the factors related to the lack of students’ willingness to perform first aid include insufficient knowledge [ 11 ], fear of hurting the victim [ 6 ], and the fact that the victim was a stranger [ 11 ].

In a lower-middle-income country such as Vietnam with 26.2 million children (i.e., 28.0% of the population in 2017) [ 14 ], data on the willingness to perform first aid across children remains poorly reported [ 15 , 16 ], despite the importance of willingness to perform first aid [ 6 , 11 , 17 – 19 ]. Vietnamese children have been suffering from a large burden attributed to injuries such as fall, motor vehicle accident, and being attacked or abused or fighting with someone [ 20 ]. In 2017, injuries led to 7400 excessive deaths in Vietnamese children aged 10–19 years old [ 21 ]. A recent Vietnamese national survey in 2013, which included high school students, indicated that 34.3% of boys and 25.1% of girls were injured at least once during the past year [ 20 ]. Though schools are encouraged to organize first aid training for teachers, staff, and students, there remains a lack of standardized formal curriculum at both regional and national levels in Vietnam [ 22 ].

To our knowledge, there are no published datasets that assess the willingness of students to perform first aid and associated factors in Vietnam. Therefore, it is essential to conduct studies reflecting the present efficacy of first aid training and recommend means to bolster training quality. Thus, this study aims to estimate the prevalence of willingness to perform first aid amongst high-school students in Hue and thus identify factors that may be associated with first aid interventions.

Study design and study population

A cross-sectional study on high school students in Hue was conducted from April to July 2020. Hue is a major education and healthcare center within Vietnam, with an estimated population of 652,572 in 2021 [ 23 ]. All high schools in Hue, in addition to other provinces in Vietnam, are required to follow a national framework provided by the Vietnamese Ministry of Education’s general education program [ 24 ]. General education comprises three levels: five years of primary education (elementary school), four years of lower secondary education (middle school), and three years of upper secondary education (high school) [ 25 ].

However, as most students in grade 12 tend to have busy schedules in order to prepare for the National High School Exam, we decided to select grades 10 and 11 students, who have more flexible schedules from high schools across Hue as the source population. There are presently 11 high schools in Hue [ 26 ], with 8328 high school students within grades 10 and 11 at the time of the study.

Sample and selection of participants

Data were collected during the baseline assessment phase of the first aid training project of Hue University of Medicine and Pharmacy. The required sample size for this study was calculated by utilizing a formula for cross-sectional studies [ 27 ] with 95% confidence level and 5% precision and accounted for the proportion of participants who have demonstrated sufficient first aid knowledge p = 0.491, as assessed in a previous study [ 28 ]. Due to the use of a multistage stratified random sampling design, the design effect was multiplied by a factor of 2. To account for participants refusing to complete or returning incomplete questionnaires, an additional 10% of the sample population was added. Overall, 844 students were included in the study population.

A multistage stratified random sampling technique was utilized to produce a representative sample of high school students from Hue. 11 public high schools within Hue were stratified into two groups, north or south schools that are separated by the Huong River. At the first stage, we randomly selected four high schools (two schools in the north and two schools in the south of the city) ( Fig 1 ). At the second stage, among 4 selected representative high schools, all classes in grades 10 and 11 were selected. Approximately 8–10 students were randomly selected in each class. We collaborated with the schools to meet and obtain agreement from the selected students and their parents. Students were asked to complete a self-reported electronic-based questionnaire on smartphones, tablets, or laptops under the research staffs’ in-person instructions. In the case of students who did not own an electronic device to get access to the questionnaire, we would provide our tablets.

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The inclusion criteria for participants included being in grade 10 or grade 11 at selected high schools during recruitment, receiving permission to participate in the study from parents or legal guardians, and having both physical and mental capacity to answer the questionnaire of the study.

Instrument development

After conducting the literature review, we developed a questionnaire to investigate the prior acquisition of first aid training, current levels of self-efficacy, and willingness to perform first aid ( S3 Table ). All selected questions were translated into Vietnamese and back-translated to English using the approach of Back-Translation for Cross-Cultural Research [ 29 ]. The translation process includes the following steps: forward translation, back-translation, back translation review and discussion by the expert panel, and finalization. A language expert, a senior lecturer in the nursing department, translated all English questions into Vietnamese. Another independent senior emergency physician back-translated those questions into the English version. The consensus panel was then carried out to ensure the two English versions were comparable. The questions had modest adjustments to fit Vietnamese culture and language throughout the translation procedure. According to Bandura (1997), “Perceived self-efficacy is concerned with people’s beliefs in their capabilities to produce given attainments” [ 30 ]. From this definition, we defined self-efficacy as the participant’s belief in their capabilities to perform first aid and save human lives. According to Bandura’s Self-Efficacy Theory, we constructed the self-efficacy scale for first aid [ 30 ]. Based on a previous study by Wei et al. in 2013 [ 31 ] which discussed the common types of injury among Vietnamese high school students [ 32 ], we decided to use a self-efficacy score calculated on the basis of six questions. The participants were then asked to rank personal levels of self-efficacy to perform each of the six essential first aid skills (including calling emergency, cardiopulmonary resuscitation, chest compression, mouth-to-mouth ventilation, immobilization of fracture, and stopping bleeding). Point for each skill could range from 1 point as “Not confidence at all” to 5 points as “Very confident.” The maximum possible score which denotes the highest level of self-efficacy for all six first aid skills was 30, a minimum score of 5 illustrates the lowest level of self-efficacy. Apart from the continuous scale, we classified the student’s self-efficacy into 5 categories as very low (<10 points), low (10–14 points), neutral (15–19 points), high (20–24 points), and very high (≥25 points).

Willingness to perform first aid by students was calculated based on three questions in a similar ranking system which was previously described [ 33 ]. Questions inquiring about self-reported levels of participant willingness to perform first aid was divided into three different circumstances: (1) a victim is a stranger, (2) the student is the only person who can help in the accident, and (3) other people are also present in the accident were used. For each of the three questions, participants were asked to rank their level of willingness to perform first aid as “fully disagree” (1 point) to “fully agree” (5 points). The maximum score of willingness is 15, and the minimum score is 3. We defined persons as being willing to perform first aid if their willingness mean score was higher than the mean score of the study population; otherwise, they would be classified as not willing to perform first aid. Also, we presented results using another definition of being willing to perform first aid which required a person to respond “agree” or “fully agree” (≥ 4 points, i.e., only positive responses) in all three willingness questions; otherwise, they would be categorized as not willing to perform first aid.

To evaluate the content and face validity of the presented questions, a panel of experts on nursing and specialists in emergency medicine at the Emergency Department at Hue University of Medicine and Pharmacy was established. The expert panel commented and approved the first draft of the survey which included questions on general characteristics (sex, age, school, class), history of injuries (number of injuries, types of most serious injury, causes of the injury), any experience with first aid training, self-efficacy, and willingness to provide first aid. Each individual item in the draft questionnaire was evaluated for readability, appropriateness, concreteness, and significance. After that, two researchers discussed the questionnaire with six high school students from Hue to collect their feedback on the readability and adequacy of the questionnaire. A quantitative pilot survey was also implemented on 50 students from the source population to create an exhaustive list of choices for the final multiple-choice questions. The time estimated to complete the questionnaire is about 20 minutes. Ultimately, the expert panel finalized the revised questionnaire which was then employed for this study.

Data analyses

In terms of construct validity, Exploratory Factor Analysis (EFA) was carried out to identify the possible latent variables that uncover the structure of items in questionnaire. First, we established the model using principal component analysis, followed by a scree plot [ 34 ] and parallel analysis [ 35 ] to determine the number of factors. The following criteria were used to identify the number of factors: a) eigenvalues larger or equal to the eigenvalue at the scree plot’s "elbow", and (b) explain more than 80% of the total variation.

After the number of factors was defined, we carried out the iterative principal factor analysis with an oblique Promax rotation method to extract factors. The items with the highest loading factor <0.4, or uniqueness >0.5 would be removed. The procedure was repeated until no more objects in the model were removed. The results of Bartlett’s test of sphericity [ 36 ] and the Kaiser-Meyer-Olkin (KMO) measure of sample adequacy [ 37 ] were used to evaluate the applicability of EFA. The Cronbach’s Alpha was also used to measure internal consistency.

All statistical analyses accounted for the multiple-stage sampling strategy with the “svy” options in Stata version 15.1 [ 38 ]. Sampling weights were employed to obtain representative estimates of the whole population of high school students in Hue, Vietnam and to adjust for non-response bias and over or under-sampling.

Weighted proportions and confidence intervals were calculated for categorical variables, the weighted mean and confidence intervals were computed for continuous variables. Univariate comparisons on participant demographics, prior first aid training, self-efficacy, and willingness were assessed using Pearson Chi-Squared, Fisher’s exact tests, or independent t-test.

To identify associated factors, we conducted a literature review and created a simple causal diagram (DAG—directed acyclic graph) to illustrate the relationship between variables [ 39 – 41 ]. VanderWeele et al. and Hernán et al. suggested that this approach would provide more valid estimates as compared to traditional biostatistical approaches, such as backward and forward selection [ 39 – 41 ].

For the continuous score of willingness, we fitted a multivariable linear regression model to explore the association between the willingness to perform first aid and the student’s personal characteristics such as their level of self-efficacy, prior first aid training (Yes/No), class, sex, and injury experience in the past 12 months (Yes/No) which required participants to be absent from school for at least one day. We also examined the associated factors with willingness to perform first aid categorized by average mean score or positive responses as described in section 2.3 using Poisson regression models with binary outcomes. As the prevalence of students who lack the willingness to perform first aid among the study population was greater than 10%, the association between these binary outcomes and independent variables would be overestimated using logistic regression. Therefore, using log-binomial regression models to directly approximate Prevalence Ratios (PRs) would be an alternative solution; however, this model often fails to converge [ 42 ]. To tackle these statistical issues, previous studies calculated PRs by employing a modified Poisson regression model with a robust error variance for binary outcome data [ 43 , 44 ]. With such a model, Chen et al. demonstrated that the results were comparable to log-binomial regression models [ 45 ].

After data analysis in Stata 15.1, R statistical software version 3.4.0 and the packages ggplot2 and ggpubr [ 46 , 47 ] were used to visualize the study’s findings.

Ethical considerations

Our research proposal was approved by the Institutional Review Board (IRB) of Hue University of Medicine and Pharmacy with the registration number: H2020/057. We also obtained permission from the executive boards of all four selected high schools. All participants and their parents were informed of the purpose of the study and explained the minimal risks involved with the participation and the confidentiality of their data. All participation was voluntary, and the respondents could quit the study whenever they wanted. All written consent forms were collected before students participated in the study. According to the Vietnamese law of children, children are defined as under 16 years old [ 48 ]. As all eligible participants in this study were 16 years old and above, they are not considered children or minors. Therefore, consent from parents or guardians was not required by the local IRB at Hue University of Medicine and Pharmacy. However, the research team did get verbal consent from the guardians of eligible students. After completing the questionnaire, every student received a reusable water bottle as a small gift as compensation for their time.

In total, 844 students were randomly invited to the study; among this group, only 798 students (94.5%) agreed to participate and completed the questionnaire ( Fig 1 ).

Study population characteristics

Table 1 shows the weighted characteristics of study participants by sex. Approximately half of the study participants were in grade 10. With regards to first aid training, only 9.1% (95%CI: 1.5–38.7%) of female students had ever attended a first aid training course, while this proportion in male counterparts was 13.6% (95%CI: 5.6–29.4%); however, this difference was not statistically significant (p = 0.159). Among those trained in first aid, only about ⅓ of participants were trained within the past year across both sexes. Participants mainly received information detailing first aid procedures from the internet (84.8%, 95%CI: 60.5–95.3%) and their teachers (63.5%, 95%CI: 35.4–84.6%). Over 15% of students (95%CI: 7.4–29.4%) experienced an injury at least once during the past 12 months.

https://doi.org/10.1371/journal.pone.0271567.t001

Fig 2 presents the weighted proportions of responses for each question regarding levels of self-efficacy and the willingness to perform first aid. Among the six first aid skills asked, participants reported low confidence for the administration of most first aid skills, except for calling for emergency services. However, with regards to willingness in the three first aid circumstances, participants mostly agreed to provide first aid, especially when they were the only person who could help victims (84.6%, 95%CI: 70.2–92.7%), as well as when the victim was a stranger (74.8%, 95%CI: 53.6–88.4%). Approximately half of the participants were willing to engage in emergency scenarios when other bystanders were also present (56%, 95%CI: 30.7–78.5%).

https://doi.org/10.1371/journal.pone.0271567.g002

Self-efficacy of students regarding first aid

In terms of self-efficacy of students regarding first aid, the preliminary EFA model revealed that three components were sufficient ( S1 Fig ). The refined model appeared to have three factors ( S4 Table ).

The pattern of factor loading and correlation matrix among the factors of an oblique rotation are presented in S4 and S5 Tables, respectively. The content of the items indicates that these three factors focus on the quick response (Emergency call), basic life support (Cardiopulmonary resuscitation, chest compression, mouth-to-mouth ventilation), and first aid for injury (Immobilization of fracture, stopping bleeding). The results of Barlett’s test and the KMO statistic show that the EFA model was appropriate. The Kaiser-Mayer-Olkin MSA was high (0.816 > 0.5) [ 49 ]. Bartlett’s test suggested that the correlation matrix was not random (p < 0.001) [ 50 ]. Therefore, our data were suitable for factor analysis.

The Cronbach’s alpha coefficient of self-efficacy scale was 0.8321. This suggests the scale has good internal consistency [ 51 ].

Table 2 presents the weighted prevalence of different levels of self-efficacy of first aid. Most students (about 70%) showed a neutral, low, or very low level of first aid self-efficacy. Male students have a significantly higher self-efficacy mean score (17.1, 95%CI: 15.5–18.8) than female students (p-value = 0.006 from t-test). Consistently, the male group tended to have a greater proportion of high (29.3% (95%CI: 22.0–38.0%)) and a very high level of efficacy (6.4% (95%CI: 0.9–34.0%)) in comparison to female students. About 46% of students with prior first aid training reported a high or very high level of self-efficacy, whereas this proportion in those without previous training was only 26%. There was not a statistically significant difference between the levels of self-efficacy between the students who were trained in the past year and those who received training more than one year ago.

https://doi.org/10.1371/journal.pone.0271567.t002

Willingness of students to perform first aid

Similar to the Self-efficacy scale, we developed the EFA model for items measuring willingness. However, because the willingness scale includes three items, we can define only 1 factor. In addition, the rotation approach is not applied to a single factor. Factor loading of items measuring willingness is shown in the S6 Table .

The results of Bartlett’s test (p < 0.001) and Kaiser-Mayer-Olkin MSA (0.687) indicate that the factor analysis can be useful.

The Cronbach’s alpha coefficient for willingness scale was 0.7649. This indicates that the internal consistency of the self-efficacy items is acceptable [ 51 ].

Table 3 indicates that half of all surveyed high school students of both sexes reported that they would be willing to perform first aid skills in all three aforementioned circumstances. The estimated prevalence utilizes two definitions that are similar in each characteristic. Students in grade 10 had a slightly higher mean willingness score as well as a higher prevalence of willingness, but this was found to be not statistically significant (p-value: 0.286, t-test). Interestingly, students without prior first aid training had a slightly higher mean score (12.2 (95%CI: 10.9–13.5)) and higher mean-based prevalence of willingness (54%, 95%CI: 33.9–73.0%), as well as positive response-based prevalence (50.9%, 95%CI: 33.7–68.0) in comparison to students who reported having received first aid training before. However, these differences were not statistically significant. Furthermore, students with a higher level of self-efficacy to perform first aid appeared more willing to administer first aid to the victim. There were no noticeable differences in the mean score or prevalence of willingness across strata of sources of first aid information received.

https://doi.org/10.1371/journal.pone.0271567.t003

Barriers and facilitating factors associated with students’ willingness to perform first aid

We asked students to rank the top three barriers which may prevent them from providing first aids. The proportion of students choosing each barrier as the first, second, and third barrier by sex was presented in Fig 3 . The three barriers that surfaced in all first, second, and third rank were fear of making mistakes and hurting victims (34.1%, 95%CI: 31.3–37.1), not yet been trained to do first aid (30.3%, 95%CI: 28.3–32.4), and forgetting first aid steps (22.9%, 95%CI: 15.5–32.3) ( Fig 3 ). Fear of making mistakes and hurting victims was more common in female students (38.2%, 95%CI: 37.6–38.8) as compared to male students (27.8%, 95%CI: 21.2–35.6) ( S1 Table ).

https://doi.org/10.1371/journal.pone.0271567.g003

Fig 4 shows the proportions of students who responded “Yes” to facilitating factors listed in the questionnaire. The most common factor that motivated high school students to perform first aid was being the only bystander in accident circumstances (83.9%, 95%CI: 74.1–90.5%), followed by “being trained to do first aids” (57.6%, 95%CI: 27.7–82.8%). The proportions of facilitating factors were not different between males and females (p = 0.683, Chi-square test) ( S2 Table ).

https://doi.org/10.1371/journal.pone.0271567.g004

Factors associated with students’ willingness to perform first aid

Based on the multivariable models from Table 4 , we found that the level of self-efficacy and prior first aid training was significantly associated with students’ willingness to perform first aid.

https://doi.org/10.1371/journal.pone.0271567.t004

In the multivariable linear regression model, compared to neutral students, students with a very low level of self-efficacy were less willing to perform first aid (β = -1.706, 95%CI: (-3.023)—(-0.39)); whereas, those with a high or very high levels of self-efficacy were significantly more willing to do such techniques (β = 0.614, 95%CI: 0.009–1.219; β = 1.64, 95%CI: 0.857–2.422, respectively). Additionally, any prior first aid training experience had a significant negative association with students’ willingness (β = -0.518, 95%CI: (-0.899)–(-0.136)).

In the multivariable Poisson regression models, only high and very high levels of self-efficacy were associated with having willingness to perform first aid, as compared to students with neutral self-efficacy. The factor of previously receiving first aid training was not statistically significantly associated with willingness in these two models.

In the present study, the willingness to perform first aid among high school students within a Vietnamese city was approximately 50%; this is lower than studies conducted across high school students in China (73%) [ 13 ], Hong Kong (83.3%) [ 52 ], New Zealand (63%) [ 53 ], and Japan (50–68.2%) [ 11 ]. However, the finding of this study is slightly higher than the results reported in Malaysia with 45.1% [ 54 ]. Overall, these differences could be due to variation in specific questionnaires and definition of willingness to perform first aid between studies. For example, one Japanese study utilized dichotomous questions on five hypothetical scenarios of cardiopulmonary arrest to estimate the prevalence of willingness to perform first aid among students [ 11 ]. Furthermore, other studies in New Zealand and China employed Likert questions which primarily focus on two scenarios, such as if the victim was a stranger or family member [ 13 , 53 ].

This study also investigated the leading factors which act as barriers or facilitators in influencing the willingness of students to perform first aid. The presented study further illustrates that the fear of making mistakes and hurting victims (38.2%, 95%CI: 37.6–38.8%) remains the most prevalent reason which prevents students from offering first aid. This finding is in line with studies conducted in other countries. For example, in Japan, the reason for unwillingness to perform CPR was the fear of inadequate performance in first aid [ 11 ]. Similarly, in Hong Kong, nearly 30% of students reported that being afraid of making mistakes and hurting victims could be a major barrier to performing first aid [ 52 ]. A similar finding was found in Malaysian students [ 54 ]. Another significant barrier for performing first aid was not receiving first aid training yet (30.4%, 95%CI: 27.6–33.2%). This result was similar to a previous study on Hong Kong high school students who reported that not being trained in first aid was the second most common reason for the reluctance to perform first aid [ 52 ].

In our study, only 9.1% of students had experienced first aid training. This prevalence was slightly lower than Hong Kong (12.3%) [ 52 ], Malaysia (17%) [ 54 ], and far below some highly developed countries such as Japan (59%) [ 11 ], New Zealand (70%) [ 53 ] where first aid training courses have been formally provided in the education system. In Norway, first aid training has become a compulsory part of the national high school curriculum, with 90% of the Norwegian population receiving at least one first aid training course within ten years [ 10 ]. On the other hand, the most prominent motivating factor to perform the first aid was the realization that one is the only one available to provide the help. This study finding was also found in another study conducted in Malaysia [ 54 ].

Apart from knowledge of first aid, self-efficacy plays an important role in initiating, maintaining, and changing first-aid behavior [ 33 ]. For example, individuals who lack self-efficacy were less likely to adopt first aid knowledge in a real situation. Recent evidence has also indicated that self-efficacy is a significant factor which influences willingness to perform first aid [ 19 , 33 ]. In this study, a low prevalence of students (11.2%) with a high or very high level of self-efficacy in performing first aid is reported ( Table 2 ). This result is slightly higher than results observed within the Japanese public (9%) [ 19 ]. However, it is lower than another study in Norway, where this percentage accounts for 57% [ 33 ].

After adjusting for school grade, sex, injury experience, first aid training experience, and self-efficacy, it was found that student willingness to perform first aid is associated with levels of self-efficacy in all three regression models. Student groups with a very high level of self-efficacy were more willing to perform first aid, whereas those with low levels tend to be more reluctant to perform the first aid. Self-efficacy is typically utilized to indicate the ability to perform specific actions. In a previous Norwegian study, self-efficacy was the strongest predictor of intended behavior to demonstrate first aid skills [ 33 ]. Several studies on the public population of Taiwan and Japan also found a similar finding [ 19 , 55 ]. Although having not received first aid training has been reported as a common barrier to performing first aid, the role of this factor is not clear when analyzing multivariable models. In the linear regression model, we found that students who received first aid training were negatively associated with willingness to perform the first aid; however, this association was not significant in the Poisson regression models. This finding should be interpreted with caution as few studies have evaluated the relationship between self-efficacy and the willingness of students to perform first aid. The results derived from the linear regression model utilized in this study were inconsistent with previous studies where first aid training was found as a significantly positive factor related to the willingness of the public to perform some first aid skills such as CPR [ 19 , 56 ]. However, another study identified that students who received the first aid training showed a lower score of attitudes toward first aid behavior than untrained ones [ 55 ], and one study reported that half of the students trained once in first aid were more likely to be afraid of attempting CPR [ 57 ]. Furthermore, having prior first aid training was modestly showed to decrease the willingness score by 0.518. While this is statistically significant in the linear regression model, it was not showed to have any association in the Poisson models. Moreover, although we acquired information of experience in first aid training, we did not collect other important factors that may influence the attempt of first aid including the type of training, quality of training, and the frequency of training. Therefore, further investigation is needed to answer these questions.

There are some strengths in this study. First, we employed the multi-stage stratified random sampling approach to select the study participants. Therefore, the presented results are likely representative of the whole high school student population in Hue. Second, to our knowledge, this is the first and largest study on student’s willingness to perform first aid skills in Southeast Asia. Third, apart from CPR skills, our survey covered other first-aid skills including stopping bleeding, immobilizing fractures, and calling emergency services, which have not been well reported in the literature.

This study also has some limitations which need to be considered. First, the study was a cross-sectional study that was unable to establish a causal relationship. Second, the study population included students who are primarily living in urban areas. Therefore, the interpretation of these results upon students living in rural areas needs to be taken with caution. Third, there were a few classes that were under or oversampled as compared to our initial target. Though we applied post-stratification weights in all surveyed analyses to partly adjust for this issue, there would still be residual bias due to sampling. Finally, as there are no international standard questionnaires which have been developed to evaluate the willingness to perform first aid at the time of this study, utilization of the self-developed instrument in this study could have led to challenges to compare the levels of willingness between countries. Moreover, our questionnaire may not have covered all aspects of this issue and potentially overlooked some key factors which influence the willingness of respondents, thus leading to potential biases in our model.

The willingness of high school students to perform first aid in Hue, Vietnam, was moderate. The most prominent factor for the willingness of students to perform first aid as an intervention remains as individual self-efficacy. The essential integration of boosting self-efficacy in first aid training can be an important aspect to reform first aid training in Vietnam. Further studies are required to explore approaches to improve both willingness, self-efficacy, and knowledge of first aid approaches in Vietnamese children.

Supporting information

S1 fig. the parallel analysis of efficacy scale..

https://doi.org/10.1371/journal.pone.0271567.s001

S1 Table. Group of barriers to performing first aid among high school students.

https://doi.org/10.1371/journal.pone.0271567.s002

S2 Table. Group of facilitators to performing first aid among high school students.

https://doi.org/10.1371/journal.pone.0271567.s003

S3 Table. Literature review for questionnaire.

https://doi.org/10.1371/journal.pone.0271567.s004

S4 Table. Factor loading of items in the self-efficacy scale.

https://doi.org/10.1371/journal.pone.0271567.s005

S5 Table. The correlation matrix of the factors after the oblique rotation.

https://doi.org/10.1371/journal.pone.0271567.s006

S6 Table. Factor loading of items in the willingness scale.

https://doi.org/10.1371/journal.pone.0271567.s007

Acknowledgments

We would love to thank Dr. Nguyen Khanh Huy, Ms. Tran Thi Nguyet, and Ms. Tran Thi Hang for their valuable feedback to improve the questionnaire. We also thank the student union secretaries in the selected high schools who helped us contact the teachers, students, and students’ parents. Also, we deeply thank our collaborators, supervisors, and study participants for their effective cooperation during the data collection procedure. Lastly, we thank Jonathan Josephs-Spaulding for his language editing of the manuscript.

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• v.6(1); Jan-Mar 2017

Effectiveness of first-aid training on school students in Singur Block of Hooghly District, West Bengal

Lina bandyopadhyay.

1 Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India

Aparajita Dasgupta

First aid is the helping behavior and initial care provided for an acute illness or injury. Students have the potential for changing the health scenario of the society if properly groomed and educated. The objective of the study is to evaluate the effectiveness of educational intervention on the first aid among middle school students of a rural school in West Bengal.

Materials and Methods:

A total of 230, 6 th and 7 th standard students were given a self-administered questionnaire for assessing their baseline knowledge about management of common injuries followed by educational intervention with a systematically devised teaching module during February to March 2016. Post intervention evaluation of their knowledge acquisition was done after 2 weeks with same questionnaire.

The baseline knowledge on the management of selected injuries was found to be insufficient among the study subjects. Paired t -test was performed to compare the pre- and post-test scores of knowledge and attitude of the students about first aid, and there was a significant change in knowledge from pretest score (mean = 1.50, standard deviation [SD] =0.47) to posttest score (mean = 6.53, SD = 1.30). To quantify the effectiveness of health education, effect size (Cohen's d) was derived. For knowledge score, Cohen's d was 5.14 with large effect size indicating highly effective impact of the training program. Significant change was also noticed regarding attitude regarding first aid as evident from increase in pretest score (mean = 1.19, SD = 0.96) to posttest score (mean = 3.17, SD = 1.03); Cohen's d was 1.88 with medium effect size.

Conclusion:

Inculcating first-aid training in the school curriculum can be a fruitful investment in ensuring proper and timely management of illnesses and injuries not only for the school children but also for the community at large.

Introduction

Henry Sigerist, the medical historian, stated that “the people's health ought to be the concern of the people themselves. They must struggle for it and plan for it. The war against disease and for health cannot be fought by physicians alone. It is the people's war in which the entire population must be mobilized permanently.”[ 1 ] Often, delay in accessing appropriate medical care and/or lack of knowledge regarding treatment results in death of the injured which can be avoided by immediate resuscitation measures. First aid, as the name implies, is the first care given to a victim of an accident, injury, or sudden illness, before the provision of advanced medical care. First aid should be aimed to preserve life, promote recovery, and prevent worsening of the victim's condition. First aider should be able to assess the victim, provide the basic care, and then direct the patient to an appropriate medical care as soon as possible. First-aid training is an important community survival skill necessary for all individuals as injuries and accidents have become the major epidemic of noncommunicable disease in India. Safety education must begin with school children since they not only represent the bulk of at-risk population with injury proneness, they also have the aptitude to learn with an innate enthusiasm to preach and practice among their family members, peers, and community. Schools are the most suitable places where proper education on the first aid can be delivered effectively due to the inherent ambience of the institution which makes them more receptive to any type of educational training.[ 2 ] However, school health programs in India give limited emphasis on first-aid training in the educational curriculum which is in contrast to the scenario of developed countries like the United Kingdom where first aid is a more frequently taught subject in the health curriculum of schools.[ 3 ] With this background, the present study was undertaken in a rural school of West Bengal where modular teaching was imparted to adolescent school children studying in Class VI and Class VII regarding selected first aid measures of common injuries/illnesses after preliminary assessment of their existing knowledge. Further, evaluation of their acquired knowledge and attitude was done to determine the effectiveness of the intervention.

Materials and Methods

This school-based interventional study was conducted in Radharani Siksha Mandir High School located in Paltagarh, Singur Block of Hooghly district, West Bengal, among students of Class VI and Class VII on February–March 2016. The middle school students were chosen keeping in view of their mid-adolescent age that makes them prone to injuries and accidents. All students of 6 th standard and 7 th standard were eligible to participate. Although educational intervention was imparted to all those present on the day of intervention, postintervention knowledge was assessed among only those students whose preinterventional knowledge score was available. Hence, out of total student strength of 260, analyses of questionnaires of 245 students was considered, i.e., the students who were present on the days of preinterventional assessment, modular teaching, and postinterventional assessment which was done after 2 weeks. After obtaining permission from the Institutional Ethics Committee of All India Institute of Hygiene and Public Health, formal approval was obtained from the Headmaster and class teachers of the two classes and data collection of baseline knowledge of the students was done using a self-administered structured questionnaire, prepared in English, and then translated into the local language (Bengali) keeping semantic equivalence. The face and content validity of the questionnaire was checked by experts in the Department of Community Medicine at the All India Institute of Hygiene and Public Health, Kolkata, West Bengal. The questionnaire contained two sections: section (1) contained student's identification in the form of class and roll number along with sociodemographic particulars and Section (II) comprised 14 multiple choice questions on two domains, namely, nine questions on knowledge of first-aid management of common injuries and five questions on attitude regarding first-aid application.

Pretest evaluation

Self-introduction about the investigator and information regarding nature of the study was explained. Informed consent was sought from each student, and the pretest self-administered questionnaire comprising both Section I and II was given to them after instructing all participants regarding the importance of providing accurate information.

Module for intervention

Analysis of their existing knowledge obtained from the pretest questionnaire was done and was utilized for preparing the teaching module. It consisted of systematically organized information on selected first-aid measures such as management skills of minor cuts, sprain, burns, fracture, foreign body in the eye, nose bleeding, insect bite, snake bite, and dog bite with relevant pictures and diagrams. Demonstration of usage of items which are usually kept in the first-aid box such as elastic bandage, tweezers, and essential drugs was done at the end of the session.

Method of intervention

The intervention was given by lecture, PowerPoint presentation and demonstration for 30 min, including 20 min of modular teaching by PowerPoint presentation and 10 min of demonstration of first-aid box contents. The module was handed over to the participants individually with the aim to reinforce their knowledge in future.

Posttest evaluation

Evaluation of the educational intervention program was assessed by conducting posttest using self-administered questionnaire comprising only Section II after 15 days. Data analysis was done using SPSS version 20 (Statistical Package for the Social Sciences Inc, Chicago, IL, USA). Excluding the incomplete questionnaire, the total questionnaire used for analysis was 230. Coding was done to assess the pre- and post-test knowledge by assigning for every correct response a value of “1” and for every wrong response a value of “0.” Maximum attainable score was “14” while minimum attainable score was “0.” McNemar Chi-square test was done to determine significant change, if any, between pretest and posttest knowledge response on each subtopic as well as change in attitude toward the application of first aid. The overall mean pretest and posttest scores of knowledge and attitude were compared using paired t -test to detect any significant change, and effect size calculation was done to assess the effectiveness of the intervention in terms of estimating the magnitude of the effect of interest.

Out of 230 students, 60% of the students belonged to Class VII and the rest in Class VI and half of them who participated in the study were girls (53.5%). The mean age of the study participants was 12.5 ± 0.73 years. Background data revealed that majority of their parents were educated up to tenth standard (48.7% fathers and 37.8% of mothers); father of 25.2% were farmers, 24.7% were daily laborers, 18.6% were doing business, 26.5% of them were skilled laborers, and 5.0% of them were in service while mothers of all students were homemakers. All of the students had heard of the term “ first aid” and out of them, only 14 of them (6 girls and 8 boys) had reported any past practical experience of administering first aid. Among those who had heard about first aid, TV/radio was the major source of information (38.7%), followed by parents (24.3%), teachers (17.4%), friends (11.7%), and relatives (4.8%). 36.5% of the students answered that there was a chapter on first aid in their science book while the rest either denied (54.3%) or could not even remember (9.2%) any such chapter. However, all of them unanimously agreed that it was not taught as a part of their syllabus.

Overall, preintervention knowledge on first-aid management was poor with maximum incorrect response for snake bite management, i.e., 218 (96.4%) and minimum incorrect for insect bite management, i.e., 112 (48.7%). After educational intervention, maximum correct response was noted in case of management of burns, i.e., 200 (87%) while minimum correct response was noted for snake bite management, i.e., 55 (67.4%) [ Table 1 ]. There was significant difference between pre- and post-intervention knowledge attainment as revealed by McNemar's Chi-square test on first-aid management of cut injury, (3.5%–86.5%) burns (3.5%–87%), sprain (9.2%–79.1%), fracture (12.6%–76.9%), dog bite (16.5%–76.1%), snake bite (2.2%–67.4%), nose bleeding (24.3%–60.9%), and foreign body in the eye (28.7%–65.2%). However, insignificant change was noted in the posttest knowledge of management of insect bite. Five questions were asked to assess the attitude of students regarding the application of first aid, and significant change was also proved by McNemar's Chi-square test [ Table 2 ] during postintervention assessment. Paired t -test was performed to compare the pre- and post-test scores of knowledge and attitude of the students about first aid, and there was a significant change in knowledge on first aid management of selected injuries from pretest score (mean = 1.50, standard deviation [SD] =0.47) to posttest score (mean = 6.53, SD = 1.30), P < 0.001. To quantify the effectiveness of health education effect size (Cohen's d) was derived. For knowledge score, Cohen's d was 5.14 with large effect size indicating highly effective impact of the training program. Significant change was also noticed regarding attitude about first aid as evident increase of pretest score (mean = 1.19, SD = 0.96) to posttest score (mean = 3.17, SD = 1.03), P < 0.001. The mean difference of attitude score was 1.8. Cohen's d for attitude score was 1.88 with medium effect size [ Table 3 ].

Comparison of correct responses related to knowledge on first aid before and after educational intervention ( n =230)

Comparison of favorable responses related to attitude before and after educational intervention ( n =230)

Comparison of pre test and post test scores of knowledge and attitude by Paired t test

Before the educational intervention, although every student replied in the affirmative about necessity of keeping first box handy, when they were questioned that where should the first-aid box be kept; 68.2% mentioned it should be kept in home only, 19.6% of them told it should be kept in school only, and the remaining students did not know exactly where to keep the first-aid box. However, in the postintervention assessment, it was overwhelming to find 100% correct response in this regard that a first-aid box should be kept handy both at school and home.

The present study revealed that all the students had heard of the name of first aid which were similar to the findings of Priyangika and Hettiarachhi in a study conducted in Sri Lanka[ 2 ] while Dasgupta et al . reported in her study that merely (15.2%) of the study subjects knew about the correct definition of the term “ first-aid.”[ 3 ] The knowledge of students regarding management of burns were found to be very poor in this study which was also reported by Shinde et al . from Pune in their study among high school students in December 2015.[ 4 ] The knowledge regarding dog bite and snake bite management was also was found to be poor. Similar findings were reported in a study conducted in a Government school of Chandigarh by Singh and Kaur among ninth standard students.[ 5 ] Regarding the effectiveness of training program about selected first-aid measures among school students, the results in this study were consistent with the findings of Muneeswari B in Tamil Nadu and Sonu and Amarjit in Chandigarh, which showed that the knowledge scores improved significantly among students following planned training program.[ 6 , 7 ] Televised material, as well as the parents, is the chief source of information about first aid among the study population which were similar to the findings of the study done in Saudi Arabia by Mobarak et al .[ 8 ] In contrast to the positive attitude of the school students toward willingness to apply first aid if necessary, as revealed in this study, Hong Kong Red Cross in their report on “Public Knowledge and Attitude on First Aid” done in 2011 commented that although their attitude was positive, inactive to learn first aid since 55% of respondents felt that it was the responsibility of medical professionals only to save life, and perform first aid and 36% felt that learning first aid might be difficult and complicated.[ 9 ] Moreover, receptivity of school students toward educational intervention was also evident from the postintervention large effect size.

Strength of the study

Teaching module development after gap analysis of baseline knowledge of school students made the content of teaching appropriate and posttest assessment after 15 days provided an ample opportunity to assess the power of retention of the knowledge among the students.

Conclusion and Recommendations

The present study revealed a perceived need for knowledge regarding first aid among school students and thus advocates that first-aid education should be made compulsory in school syllabus. This would not only enhance their skills toward emergency management of injuries but is also a crucial step forward to disseminate first-aid message in the community. The necessity of keeping a first-aid box with recommended equipment and medicines at ready disposal both at home and school would go a long way in saving a precious life.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.