Frequency and quality of first aid offered by older adolescents: a cluster randomised crossover trial of school-based first aid courses

Introduction

The ability to provide first aid is an important set of skills for anyone of any age to have. The provision of appropriate first aid to an ill or injured person can save a life, mitigate the severe consequences of sudden illness or injury, address minor injuries in a timely and effective way, and create a caring and reassuring environment until emergency services arrive.

First aid skills may be particularly important for groups who are often exposed to illness and injury, such as children and adolescents (Wilks & Pendergast, 2017). Rates of hospital admissions for conditions such as anaphylaxis are rising, particularly in the 5–14 year age group (Mullins, Dear & Tang, 2015). Accidents and injuries are a leading cause of hospitalisation, morbidity and mortality among children and adolescents in Australia and worldwide (Australian Institute of Health & Welfare, 2018; Global Burden of Disease Pediatrics Collaboration, 2016; Pointer, 2014). In Australia, the most common mechanisms of injury for young people aged between 11 and 17 are falls, road transport and intentional self-harm (Mitchell, Curtis & Foster, 2018; Pointer, 2014). Transport-related injuries, collisions and falls are also the most common causes of major paediatric trauma in 11–15 year olds in the state of Victoria, and these injuries primarily occur in settings outside the home and school (e.g. on roads, streets and highways, in recreation areas, and in athletics and sports areas; Beck et al., 2019). This suggests that illnesses and injuries in young people are common and take place in areas where bystanders, such as peers, may be present and able to offer first aid.

One way to increase the proportion of young people equipped with first aid skills is to offer first aid training to students in schools. Schools have an influential role in promoting adolescent health and wellbeing, and provide access to the majority of young people from diverse socio-economic backgrounds. Although first aid training for students is not currently mandatory in Australia, schools appear to be supportive of first aid courses for students, and first aid principles align well with Australian school curriculum goals of developing students’ knowledge, skills, self-efficacy and resilience across various life domains (Wilks & Pendergast, 2017).

Many studies have assessed the effectiveness of school-based first aid programmes. Systematic reviews indicate that first aid training appears to improve students’ knowledge and skills in areas such as injury prevention, cardiopulmonary resuscitation (CPR) and use of automatic external defibrillators (Plant & Taylor, 2013; Reveruzzi, Buckley & Sheehan, 2016). However, existing evidence for the effectiveness of school-based first aid programmes is limited by a lack of well-designed studies. Common methodological issues include a lack of random allocation, absence of comparison or control groups, small or biased samples, failure to measure students’ first aid knowledge or experiences prior to completing school-based first aid training, and a lack of justification for the topics addressed in the training (Reveruzzi, Buckley & Sheehan, 2016). These issues indicate that more rigorous study designs are needed to examine the acquisition and retention of first aid skills in adolescent students undertaking school-based first aid training. Studies that assess whether first aid skills are used, and used appropriately, outside of learning and skills testing settings are also needed to understand whether and how adolescents apply first aid when faced with a real-life emergency.

The current article reports on a subset of results from a randomised controlled trial which compared a physical first aid (PFA) course with an equivalent length mental health first aid course (teen Mental Health First Aid; tMHFA) to assess the effects of each type of training on older adolescents’ PFA behaviours 12 months after the training. This study aimed to establish whether the training programmes produced differences in the frequency with which students offered and provided PFA to peers experiencing an illness or injury and the amount of first aid provided that was in line with current PFA guidelines. It was hypothesised that students receiving the PFA course would offer PFA more often, provide PFA more often, and provide more appropriate PFA than students receiving the tMHFA course. The study also aimed to ascertain which PFA actions were most commonly performed amongst this age group and why first aid might not have been provided in situations where a peer required PFA. Lastly, the study aimed to assess predictors of appropriate PFA.

Materials and Methods

The description below outlines the sections of the trial design and study methodology relevant to the aims of this research. It conforms to the CONSORT 2010 statement and extension for cluster randomised trials (Campbell et al., 2012). Full details of the trial and methodology can be found in Hart et al. (2018).

Results

Table 2 shows the number of students allocated to each intervention, participant numbers at each time point and data on the number of students who encountered a person needing PFA, offered first aid, and provided appropriate first aid. The mean age of students completing the baseline survey was 15.87 years (SD = 0.52); 44.7% were female and 72.5% spoke English as a first language (see Hart et al. (2018) for full details). Of the students responding to the section on experiences of first aid, the mean age was 15.87 years (SD = 0.51), 46.4% were female and 76.6% spoke English as a first language. Chi-square analyses indicated that at both baseline and follow-up, there were no significant differences between interventions regarding the number of students who had encountered a person needing PFA in the last 12 months, or in the proportion of students who offered help to the person they knew best. However, at both time points, the group receiving PFA training provided significantly more appropriate first aid than the group receiving tMHFA. Logistic regressions that assessed intervention × time interactions for appropriate provision of PFA (controlling for age, gender, English as first language, school, intervention received, number of first aid sessions attended and whether appropriate PFA was provided at baseline) confirmed that appropriate PFA provided at baseline was the only significant predictor of appropriate help at each time point. Receipt of PFA training did not appear to improve the frequency or quality of students’ first aid actions.

Of the total number of open-ended responses describing first aid provided to a peer, 60.3% were categorised as inadequate or ineffective. These responses included: talking to, calming or comforting the person with no mention of other actions taken; taking a peer to the school nurse or sick bay; offering assistance after the emergency had passed (e.g. ‘Offered to carry person’s books whilst their leg was in a moon boot’); and responses that did not describe a specific first aid action (e.g. ‘Asked if there was anything I could do for them’, ‘Assist them in any way possible to make sure they were okay’). Table 3 summarises the most common types of appropriate PFA provided to a peer across both time points.

Table 4 summarises reasons given for not providing first aid at both time points. The most common reasons were because someone else was already providing first aid, because the student perceived their skill set or experience to be inadequate and because practical constraints precluded the provision of first aid.

Discussion

The results of this study indicate that brief PFA training does not appear to affect the frequency of appropriate first aid actions performed by older adolescents 12 months later. Despite significant differences between the PFA and tMHFA groups at follow-up, pre-existing differences at baseline suggested that the programme was not effective at changing behaviour. A lack of improvement in, or retention of, adolescents’ first aid skills at 12 month follow-up is an atypical finding in the literature on school-based first aid programmes (Moore, Plotnikoff & Preston, 1992). One explanation for this finding may be that the bespoke, shortened PFA course used in this research may have reduced effectiveness when compared with lengthier, accredited PFA programmes, although at just under 4 hours duration it is somewhat longer than other first aid courses assessed in school settings (Reveruzzi, Buckley & Sheehan, 2016). This finding may also have resulted from the methodology used to assess first aid responses. Other studies of school-based first aid programmes use knowledge or skills assessments to evaluate students’ first aid competencies, while this research used an open-ended, free text response question. Many responses were brief or lacked key details which would have enabled coders to assess the adequacy of students’ first aid actions and assign a valid code. The resultant loss of data likely contributed to the null effects found in the analyses.

Analysis of the types of appropriate first aid provided to peers indicated that first aid was provided for injuries such as wounds, sprains/strains and fractures/dislocations. This highlights the importance of designing first aid courses for young people that enable them to address injuries and illnesses common to adolescence (Reveruzzi, Buckley & Sheehan, 2016). Adolescents who were unable to help a peer who needed first aid cited a range of reasons for this, including that others were already providing first aid (reported more often by PFA participants) and a belief that their skills and experience were not adequate (reported more often by tMHFA participants). It appears that only the reason related to lack of skill or experience has been reported previously in this age group (Kanstad, Nilsen & Fredriksen, 2011; Ma et al., 2015; Omi et al., 2008). These results should be regarded as preliminary as it is uncommon for studies to examine reasons for not providing first aid in response to a real-life emergency. Future research should attempt to replicate these findings with different, larger samples of adolescents and endeavour to understand these reasons in greater depth. Semi-structured interviews may offer insight into why adolescents with first aid training believe they lack the skills to provide first aid, or why they may feel reluctant to provide first aid to a peer (c.f. Wilks et al. (2016), who found that primary school-aged children were less likely to feel confident helping a friend or same-aged stranger than a family member). This information could be used by course developers to address perceived barriers to helping among adolescents during training, and assess whether this affects rates of first aid provision.

Although further research is needed to better understand how first aid skills can best be acquired, retained and used outside of learning and testing environments, the results of this study suggest that schools can maximise the utility and relevance of school-based first aid programmes in two main ways. Firstly, schools can endeavour to ensure that their first aid programmes contain topics that are appropriate and useful for the target age group. The results of this research imply that the most commonly used first aid skills were performed in response to injuries and illnesses common to adolescence. Courses which incorporate content that reflects students’ developmental stage alongside basic life support steps may increase the likelihood of young people applying first aid to a peer in an emergency, which may ultimately contribute to reductions in injury-related morbidity and mortality (Tannvik, Bakke & Wisborg, 2012). A second, complementary suggestion for schools is to consider introducing a first aid educational pathway into the curriculum that enables students to learn age-appropriate first aid skills during each school year (De Buck et al., 2015; Wilks & Pendergast, 2017). A first aid educational pathway, such as the one developed by De Buck et al. (2015) may serve many purposes, including revision of knowledge and skills from previous years alongside acquisition of new skills, improving students’ confidence and competence in applying first aid, and improving teachers’ confidence in teaching first aid to students of any age. The pathway could also be developed in consultation with students to ensure that it addresses topics and concerns that are important to them, such as particular barriers to providing first aid (see Table 4). Embedding regular first aid lessons into the school curriculum, and including student input in their development, can help to normalise the subject and increase students’ comfort, self-efficacy, knowledge and skills in this area (Wilks & Pendergast, 2017).

This research responds to calls in the first aid literature for more randomised controlled trials (Van de Velde et al., 2009), particularly ones assessing school-based first aid training and first aid behaviours (Reveruzzi, Buckley & Sheehan, 2016). The study used a rigorous cluster-randomised crossover trial methodology with longitudinal follow-up, and recruited a large, diverse sample of schools and adolescents. The structure and timing of each first aid intervention was matched to improve the likelihood that any changes to behaviour would be due to programme content and not an artefact of undertaking an activity outside of the usual curriculum. The content was designed to cover key first aid skills, such as CPR, and first aid injuries and emergencies common to adolescence, such as strains, sprains, wounds and anaphylaxis, to increase its relevance to, and utility for, the target audience (De Buck et al., 2015; Reveruzzi, Buckley & Sheehan, 2016). The findings also have ecological validity, as they provide some insight into whether and how first aid skills were used outside of learning and testing environments, and why they were not used.

Despite these advantages, limitations remain. Not including follow-up surveys between baseline and 12 month follow-up means that the research could not examine whether knowledge or motivation to assist were retained up to a point (e.g. 3 or 6 months after training; Andresen et al., 2008) before dropping off. As the questionnaire did not ask about prior first aid training at baseline, or whether students had undertaken additional first aid training between baseline and follow-up, the analyses could not control for these variables, or clarify whether any changes were due to the first aid training delivered as part of this research. The questionnaire also did not ask students what the problem requiring first aid was, and so it is not known whether the first aid provided was appropriate for the situation, or administered effectively; students’ ability to correctly perform the first aid actions they were taught was not assessed. The small number of students responding to the follow-up survey, and the brief explanations of their first aid actions, precluded a more thorough assessment of first aid behaviour and reasons for not helping at 12-month follow-up. As the research relied on self-report and students’ recollection of events that may have happened several months earlier, recall bias may have affected the quantity, quality and validity of the data. Lastly, a large proportion of open-ended responses could not be coded, which considerably reduced both the quantity and quality of data. Several of these limitations are being addressed in another large-scale trial comparing tMHFA and PFA which is currently underway, for example offering remuneration to increase participation rates, asking what the problem requiring first aid was and including questions about intentions and confidence to provide first aid to a peer experiencing different illnesses and injuries. It is anticipated that these changes will enhance the amount and quality of data on first aid actions performed by adolescents.

Conclusions

The findings of this research highlight the need for more rigorously designed longitudinal studies to establish the effectiveness of school-based first aid programs, and more research that focuses on first aid behaviour in response to emergencies that adolescents may encounter. An improved understanding of first aid skill retention and use will contribute to the development of engaging and relevant health education for young people.

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