Post-Crash Trauma Care: First-Responder Training for the Tra c Police in Makwanpur, Nepal; A Pre and Post-Intervention Cross-Sectional Survey


 BackgroundThe World Health Organisation has estimated Nepal's road traffic fatality rate as one of the highest in South-East Asia. Road-crashes are the 7th leading cause of mortality in Nepal, but there is currently a lack of nationwide emergency medical services. We developed, designed and evaluated the feasibility of a first responder training programme for the traffic police in Nepal.Methods39 traffic police officers in Makwanpur District participated in the study and 29 attended the 3-day first response course. A training needs assessment survey was conducted with participants prior to course design. A knowledge and confidence pre-test was followed-up by post-testing. Participants were supplied with a trauma-pack and asked to complete a report form when first-responder skills were used. Post-testing and follow-up survey were conducted at 6-months which explored experiences of applying first response skills.ResultsPre-course needs assessment showed that 97% of the participants believed that giving first-aid was their responsibility;95% had experience of transporting road-crash victims to hospital with a range of injuries. Low levels of first-aid training and a lack of standardisation were reported. Knowledge and confidence levels were low in pre-test. Post-test knowledge scores improved by 40% to 75%. Confidence levels improved post-course but were reduced at 6-months. In the 6-month study period, participants attended 303 road-crashes. 44% of the participants had used at least one first-response skill from the course; applying skills on 92 occasions, though incident report-forms were frequently not completed. ConclusionsDelivering a first-response programme for the traffic-police is feasible. Knowledge could be retained and used, and skills were in frequent demand. Barriers to providing treatment included; patient already en-route to hospital; resistance from relatives or bystanders and competing police duties. Further studies will need to reinforce the need to capture the use of incident report forms when first responder skills are applied. It is feasible practically and financially to extend the training to cover other districts/all of Nepal as a low-cost measure to combat road traffic injury in the absence of formal emergency medical services.


Abstract Background
The World Health Organisation has estimated Nepal's road tra c fatality rate as one of the highest in South-East Asia. Road-crashes are the 7 th leading cause of mortality in Nepal, but there is currently a lack of nationwide emergency medical services. We developed, designed and evaluated the feasibility of a rst responder training programme for the tra c police in Nepal.
Methods 39 tra c police o cers in Makwanpur District participated in the study and 29 attended the 3-day rst response course. A training needs assessment survey was conducted with participants prior to course design. A knowledge and con dence pre-test was followed-up by post-testing. Participants were supplied with a trauma-pack and asked to complete a report form when rst-responder skills were used. Posttesting and follow-up survey were conducted at 6-months which explored experiences of applying rst response skills.

Results
Pre-course needs assessment showed that 97% of the participants believed that giving rst-aid was their responsibility;95% had experience of transporting road-crash victims to hospital with a range of injuries. Low levels of rst-aid training and a lack of standardisation were reported. Knowledge and con dence levels were low in pre-test. Post-test knowledge scores improved by 40% to 75%. Con dence levels improved post-course but were reduced at 6-months. In the 6-month study period, participants attended 303 road-crashes. 44% of the participants had used at least one rst-response skill from the course; applying skills on 92 occasions, though incident report-forms were frequently not completed.

Conclusions
Delivering a rst-response programme for the tra c-police is feasible. Knowledge could be retained and used, and skills were in frequent demand. Barriers to providing treatment included; patient already enroute to hospital; resistance from relatives or bystanders and competing police duties. Further studies will need to reinforce the need to capture the use of incident report forms when rst responder skills are applied. It is feasible practically and nancially to extend the training to cover other districts/all of Nepal as a low-cost measure to combat road tra c injury in the absence of formal emergency medical services.

Background
Road tra c injuries (RTIs) globally kill more than 1.36 million people each year and leave between 20 and 50 million people with non-fatal injuries. They are the 8 th leading cause of death among all age groups and distressingly, are the leading cause of death for children and young adults aged 5-29 years 1 .
It is estimated that more than 90% of all trauma related deaths occur in low-and middle-income countries (LMICs) 2 . There is a strong association between the risk of a road tra c death and a country's level of income; with an average rate of 27.5 deaths per 100,000 population, the risk is more than 3-times higher in low-income countries than in high-income countries where the average rate is 8.3 deaths per 100,000 population 1 . In their 2018 Global status report on road safety, the World Health Organisation (WHO) identi ed there has been no reduction in the number of road tra c deaths in any low-income country since 2013 1 .
The United Nations have categorised Nepal as one of the "least developed" countries of the world, indicating that it has low income and a scarcity of domestic nancial resources 3 . RTIs are a signi cant public-health burden in Nepal, with increasing levels of morbidity and mortality 4 . In 2017 there were 7524 RTI deaths; 4.11% of all deaths in Nepal were attributed to transport injuries, making it the 7 th leading cause of death in the country 3 .
An essential component in reducing mortality and morbidity for RTI victims is to have good post-crash, emergency care systems in place to ensure timely treatment. Effective care of the injured requires a series of time-critical actions, beginning with immediate activation of the emergency medical services (EMS), then continuing with care at the scene, prompt transport, followed by facility-based emergency care 5 .
Organised prehospital trauma care has been shown to be effective in reducing death and disability from RTI. A study comparing prehospital mortality rates identi ed that deaths occurred at higher rates in LMICs (81%) when compared with highly organised emergency medical services in high-income (59%) settings 6 .
Prehospital care in Nepal is sub-optimal, and with a few notable exceptions, there is a lack of regulated and standardised EMS systems 7,8,9 . Most ambulances are not crewed by trained emergency medical technicians or paramedics and are poorly equipped to manage trauma emergencies 7,8 . The majority of patients arriving in the emergency departments arrive by non-ambulance transport; taxi, private-vehicle, bus and motorbike 7 .
Research conducted in other LMICs has demonstrated that lay-people trained as rst responders applying rst aid skills at the scene of a road crash can make a signi cant difference to outcomes 11 . The WHO has stated that in countries with limited or delayed access to care, trained lay-responders can be an effective bridge to formal prehospital care 5 .
The Nepal Injury Research Centre (NIRC) was established in Nepal in 2017 through a research grant from the National Institute for Health Research in the United Kingdom. The aim of NIRC is to build capacity and capability for research to inform effective injury prevention and rst response across all sectors of Nepali life and work. As part of this aim, a First Response Reference Group (FRRG) has been formed. The FRRG is a panel of 16 experts and key stakeholders involved in EMS, rst response and rst-aid services in Nepal. These experts were recruited due to their position in government institutions, their recognised expertise and following recommendation by governmental o cials. The FRRG advocate for excellence in rst response through the application of research evidence to the National Advisory Committee for Injury Prevention and Control. At an early meeting of the FRRG, members identi ed training of the police as rst responders as one of the top 5 areas for prioritisation.
Following a road tra c collision the Nepal Tra c Police (NTP) are usually the rst o cial response and reliable presence at the scene 8 . In our study, we sought to develop, design and evaluate the feasibility of a bespoke rst-responder trauma training programme for the NTP. There is limited research on injuries occurring to residents of Nepal, including road tra c injuries 10 . There is a paucity of research on the tra c-police o cers' experience of, and training in, providing emergency care at the crash scene.

Methods
This study used a before and after cross-sectional survey design and was conducted in the Makwanpur district in Province 3, South of Kathmandu, Nepal. The district has a population of 420,000, with 45% being children <18 years of age. The district centre is Hetauda, where 20% of the district's total population live 12 . Makwanpur district has a mixed geographical terrain, ranging from low-land (<500 m) to high hills (up to 3500 m) 14 and it re ects the range of socio-economic settings found in Nepal 15 , thus results from studies in this district have the potential to be generalizable to other districts across Nepal.
The study team worked with the Nepal Red Cross Society (NRCS), an established non-pro t organization and auxiliary to the government in the humanitarian eld. Based in Kathmandu, the NRCS has extensive experience in providing rst-aid training for community groups, businesses and government bodies 13 .
The study participants were tra c police o cers from Makwanpur district. Provision of rst aid is made explicit in the NTP mission objectives 16 . The study sample aimed to include all operational tra c police o cers in the district. The study was designed with three phases; Phase 1 -the pre-intervention phase; Phase 2 -the intervention phase; Phase 3 -the post-intervention phase.

Phase 1: Pre-intervention Phase
A training needs assessment of individual tra c police personnel working in Makwanpur district was conducted. A structured questionnaire (a combination of open and closed questions) was used to conduct face-to-face surveys with individual tra c police personnel (Additional File 1). The survey explored their prior training in rst aid and experience of transporting and/or providing rst aid to injured persons. All operational tra c police in the district were invited to participate in the study. All interviews in phase 1 and phase 3 were conducted in the Nepali language by Nepalese researchers.
The information from the survey was then used to inform the design and content of a 3-day Trauma First Responder Course. Written agreement was entered into with the NTP at national and local levels for the tra c police o cers to participate. It was anticipated that not all of them would be able to engage with the training, because of the need to maintain an operational presence on the roads in the district.
A bespoke trauma-focussed rst responder programme (Additional File 2) was developed and planned incorporating content guidance from two main sources; the International Federation of Red Cross and A 20-question pre-test exploring the participant's rst aid knowledge and a 5-question Likert con dence scale was conducted before the training (Additional File 3). Immediately after completion of the training, a post-test using the same questions was completed. In addition, an evaluation of the overall training programme was also collected at the conclusion of the training.
Scores for the pre-test and post-test assessments were pooled for the cohort of police o cers, so that no individual o cer was at risk of being penalised for their level of knowledge.
Four, fully-packed, trauma response backpacks were supplied to be carried in each of the district tra c police vehicles. The NRCS trainers also distributed incident report forms to all course participants to be completed after each patient encounter for the six month period of follow-up after the training (Additional File 4). Posters encouraging participants to complete the forms were distributed to the district police stations.
Phase 3: 6-month Follow-up A RE-AIM evaluation 19 was conducted at 6-months post-training, to assess the extent to which the participants had incorporated rst response skills gained from the training into practice. The participants were individually surveyed to evaluate their experience of applying rst response skills in the eld (Additional File 5). The participants also re-took the post-test to analyse their retention of rst aid knowledge and self-perceived con dence levels. Incident report forms were collected from the police stations.
To assess the potential costs of providing rst response training to all tra c police in Nepal, we measured resources used, and the costs incurred of all aspects of the rst responder training programme e.g.. training materials, equipment, training personnel, and requirements.

Phase 1: Pre-intervention Phase
As part of the training needs analysis, all 39 tra c police o cers were surveyed about their experience of being trained in and applying rst aid. 38 (97%) of the 39 agreed that rst-aid was part of their responsibilities.

First Aid Training and Equipment
Just over two-thirds of the participants (n=25; 64.1%) said they had received no training in rst-aid. Of those that had received the training (n=14; 35.9%), the median (IQR) time since they had last received the training was 3 (1,9) years. The median (IQR) length of the training was 8 (4,24) hours. The rst aid training was provided by a number of different organisations outlined in Table 1. Of the 14 participants who had been trained in applying rst aid, 7 (50%) said they had no access to rstaid equipment at the time of interview. Of those that had access to a rst aid pack, the equipment mainly included wound dressings and triangular bandages.

Experience of First Aid and Transporting the Injured
Of the 14 trained in rst aid, 7 (50%) had applied rst aid in the previous 12 months. In that time period, rst aid skills were applied a median (IQR) frequency of 50 (3, 99) times per participant. Of the 39 participants, 37 (95%) had experience of transporting RTI victims to hospital with a wide range of injuries. These injuries are listed in Figure 1: The participants who had been trained in rst-aid and who had access to some rst aid equipment (n=7) were asked about what di culties they faced when doing rst aid at the scene of a road tra c collision (RTC). Three topics emerged; (1) lack of equipment; (2) lack of an ambulance for transport; (3) fear of criticism from the public when giving care.

Phase 2: Intervention Phase
Twenty-nine participants were released from operational duties to attend the 3-day rst responder course, thus reducing the initial sample by 10 (25.6%). They were asked to complete a 20-question pre-test about their knowledge of rst aid.

Pre-Test Knowledge of First-Aid
Nearly all the participants (n=28, 96.5%) were able to correctly identify the purpose of rst aid, but less than a quarter (n=8, 20.7%) were able to list the correct sequence of rst aid priorities at a crash scene.
Around a third of the participants (n=10, 34.5%) correctly identi ed how to open the airway, however over two-thirds (n=27, 93.1%) knew how to check for breathing. Two participants (6.9%) knew the correct ratio of chest compressions to rescue breaths for cardiopulmonary resuscitation (CPR), but 11 knew the correct chest compression rate.
Just over a quarter of the participants (n=8, 27.6%) knew to prioritise applying direct pressure to a bleeding wound, however nearly three-quarters (n=21, 72.4%) knew some of the signs of shock. Five (17.2%) of the participants knew when to apply a tourniquet. Seven (24.1%) of the participants know not to give people something to eat or drink when they were in shock.
When identifying priorities in mass-casualty situations, 12 (41.4%) of the participants gave the correct answer. However, 17 (58.6%) were able to identify the correct colour of the triage label for a given incident. A summary of pre-test knowledge scores are shown in Table 2. Pre-Test Con dence in Applying First Aid Con dence levels in applying rst-aid across a range of skills in practice was low, with a mean average con dence level (con dent or very con dent) of 32.6% (Table 3). The post-test comprised of the same 20 multi-choice questions on the participants knowledge of rst-aid as the pre-test. The post-test showed a marked improvement in rst-aid knowledge (Table 4); more than doubling the mean average scores to 74.86%; an increase of 39.35%. There were improved results across all the questions and key subject areas.

Post-Test Con dence -Applying First Aid
Post-test con dence levels also showed an improvement in con dence with an average of 88%; an improvement of 45% on the pre-test score (Table 5). Twenty-seven participants were interviewed at the 6-month follow-up point. Two tra c police o cers were lost to follow-up as they had been transferred to alternative police duties.
Participants (n=27) reported that they had attended a total of 303 RTCs where people had been injured during the six month period of follow up. 12 participants (44.4%) stated that they had applied rst-aid to RTI victims on 92 occasions, with a median frequency of 2.5 (IQR 1,8) times in that time period. The most frequently used skills were; scene assessment, patient assessment, haemorrhage control, extricating patients from the wreckage and providing reassurance (psychological rst-aid). 81% (n=22) stated they had access to rst-aid equipment.

Perceived Barriers to Applying First-Aid
Several issues emerged when exploring barriers to providing rst response care at the scene of RTCs.
Delays in arriving at the scene meant that patients were already transported to hospital by the public.
Reasons for the delay included late noti cation and lack of transportation to the scene, although the frequency of these issues was not identi ed.
Pressure from the public to just transport the victim and not deliver rst aid. Some participants felt that they should have a badge on their uniform to show the public they were trained rst responders and that this may reassure the public that it was appropriate to allow the police o cer to perform rst aid.
Competing police duties. Participants identi ed that sometimes they had to prioritise other activities at the scene, such as clearing the road, mapping the RTC and arranging transportation before they could administer rst aid.
Lack of support from senior o cers. Participants felt that there was a lack of encouragement to do rst-aid from more senior ranks within the police force.
Lack of equipment/stretcher. Participants said that they sometimes arrived on scene without rst-aid equipment. Reasons cited were that they did not respond in a police vehicle or in the haste to get to the scene, they had left the trauma pack at the police station. There are only 4-police vehicles available across the whole district.

Knowledge and Con dence
The mean average rst aid knowledge score at 6 months was 57.05%, a drop of 17.81% from the postcourse (Table 7). No particular question or key subject area identi ed any particular weakness. The con dence level averaged 67% at 6 months; a drop of 21% from the post-course (Table 8). Only 4 incident report forms were collected in the 6-month data collection period, completed by three (11%) of the 27 staff available for follow up. A range of reasons for not completing the forms were given.
Forgetting and time pressure were the most common. Lack of support and reinforcement from senior managers was also cited, along with thinking someone more senior would complete the documentation.

Training Course
None of the course participants felt that any of the course content should be dropped, although 41% (n=7) felt that the course should be longer.

Discussion
The RE-AIM framework 19 has become widely recognized across a range of disciplines as a valuable tool to guide development and evaluation of public health interventions intended for wider dissemination. The acronym stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance which together are used here to help determine the impact of the rst responder training intervention for the tra c police in Makwanpur District.

Reach
The bespoke rst responder trauma training programme reached three-quarters of the targeted population; operational tra c police o cers in the district. Co-operation from the district police inspector ensured a high take-up of course places, but reach was naturally affected by the need to maintain a police presence on the roads. The enthusiasm for the training was a re ection of how so many of the participants felt that applying rst aid skills was a part of their responsibilities. Indeed, rst aid is made explicit in the NTP mission objectives which state that the police should "Render assistance to public in various stressful conditions such as prompt rst aid to accident victims" 16 .

E cacy
Within the RE-AIM framework 19 , effectiveness is de ned as the success rate of the intervention to achieve its intended goal(s). In our study, we sought to develop, design and evaluate the feasibility of a bespoke rst-responder trauma training programme for the tra c police in Nepal.
We have shown that we were able to develop and design a rst-responder course focussed on managing traumatic injuries at RTCs. Studies examining rst-aid training curricula in LMICs have shown signi cant heterogeneity 11 . Our study was designed using subject expertise and local expert knowledge and adaptation of pre-existing curricula 17,18 , and took into account the prior knowledge and experience of the course participants. The course combined theory with 'hands-on' simulation. Simulation is a key training modality in learning trauma care 11 .
The pre-intervention data showed that Nepal tra c police were attending road tra c crashes and transporting casualties with limited or no rst aid training and limited emergency resources. The range of injuries include wounds and bleeding, fractures and head and internal injuries. This is not uncommon in LMICs 20,21,22,23,24 . Previous studies have shown that where casualties are treated and/or rushed to hospital by untrained police or bystanders, they have much poorer outcomes and are more likely to die than if looked after by emergency medical personnel or trained rst responders 24,25,26,27 .
Three-quarters of the participants had received no previous rst aid training. Therefore, unsurprisingly, pre-intervention levels of rst aid knowledge and con dence were low and for those participants that had received rst aid training, there was no common course length or xed refresher period. Experts have identi ed that there is little evidence addressing the best length of time for a rst aid course 28 . Instead advising that the individual needs of the learner or learner group will dictate the course content and hence the course duration. Many of the course participants said they would have liked it to be longer. Our 3-day training was based on the balance of achieving the course learning outcomes, against the need to maintain tra c police operations.
The knowledge of rst aid and con dence in applying those skills in practice improved signi cantly postintervention. This dropped a little at 6-months, but not to pre-intervention levels. At follow-up, some of the participants in our study identi ed the need for refresher training and indeed, this is an important part of retaining knowledge and con dence. Research conducted with lay rst-aiders in Nepal has found that retention of rst aid skills reduces signi cantly over time and concluded that rst aid skills should be refreshed annually 29 . Other studies have shown increased retention of knowledge and self-assessed con dence in refresher training at 6-months 30,31 . Frequency of retraining must be based on a balance between the need to maintain skills and the practicalities, including nancial, involved in mandating refresher courses at frequent intervals.

Adoption
The training programme was delivered at the Police headquarters in Hetauda. The training was conducted by local and national trainers from the Nepal Red Cross Society, using the curriculum developed by NIRC. Participants were commended for their high level of enthusiasm and motivation 32 .
The local police commander also participated on most of the training days. National support for the research was also gained and permission given by the National Tra c Police Headquarters (Tra c Directorate) in Kathmandu.
Training the tra c police is not only feasible, but has the capacity to have a long term impact on clinical outcomes. When applied correctly, rst aid treatment for trauma victims has been reported to show signi cantly reduced mortality and morbidity 26,33,34,35,36 .
Knowledge and con dence improved as a result of the training and this was carried through in to the eld, with participants using their new skills frequently during the study period. It was found that police o cers were not only applying rst aid skills in practice, but were often the rescuer, extricating the RTI victim from the wreckage. Moving and handling patients were areas where they maintained selfcon dence through the post intervention phase.

Implementation
At the program level, training was delivered as intended by the trainers from the NRCS in strict adherence to the training curriculum, to ensure intervention delity. Having the trainers from NRCS was advantageous as the trainers were con dent and had many years of experience providing rst aid training across Nepal.
The training was conducted with oversight by the NIRC team and it was evaluated by the trainee at its conclusion. Feedback on the training experience showed the majority of the participants rated the training's overall value as either 'excellent' or 'good'. The training was exible whilst maintaining delity to the original planned timings and duration so as to meet with the other competing duties of the tra c police.
The cost of three-day rst responder training course (including the trauma pack) was £3,682.87 (£127 per trainee). A summary of the rst responder training course costs and associated trauma pack components are listed in Table 9.

Maintenance
There were a number of barriers and facilitators to maintaining the application of rst-responder skills to RTI victims. At an organisational level, the support both locally and nationally was essential for this type of intervention to succeed. There was a change of local police leadership part-way into the research that may have impacted on the level of support locally. Participants identi ed that they hadn't always felt supported or encouraged to apply their new rst responder skills in practice.
Although the tra c police are frequently the rst o cial presence at the scene of the RTC, delays in being activated and arriving on scene were identi ed by participants as factors resulting in the RTI victim being removed from the scene prior to their arrival. The lack of an identi able, national, 3-digit phone number to summon the emergency services promptly may be a contributory factor to these delays. Walker et al 7 have reported some success with the introduction of the '102' number in Kathmandu and other regions.
As the general public are frequently on scene before the police, having trained community rst responders also makes intuitive sense. Research in other LMICs has shown this is feasible and can make a difference 11,21,26,27 .
Having arrived on scene, although participants were able to frequently apply their skills for patient care, they sometimes felt pressured by the public to prioritise transferring the patient to hospital. There was a lack of public recognition that they were trained rst responders, and that providing rst aid may be more bene cial than immediate transportation. Possible solutions to this problem would be wearing an identi able rst responder badge on their uniform and, if expanded nationally, a publicity campaign to inform the general public of their additional role.
Post-incident, there was a limited return of incident report forms. As time pressures and forgetting were identi ed as reasons, this would require greater reinforcement in training, and for the process to be built in to the systematic reporting of RTCs and enforced by senior staff, were the training to be rolled out nationally.

Strengths and Limitations
Strengths of this study include that the course was designed after the training needs assessment, and that it was based on published guidance. It was delivered by experienced and recognised rst aid trainers.
There was good interest and co-operation from the district police and the participants which resulted in three-quarters of o cers being trained, and we were able to follow up 27/29 (93%).
Asking participants to recall the frequency of using rst aid skills is at risk of under-reporting or overreporting due to recall bias. The limited number of contemporaneous incident report forms has meant a reliance on data from the self-reported use of rst responder skills across the 6-month follow up period.
Although it is clear that participants have been applying their rst-aid skills; without the forms, it is not possible to determine the validity of their responses.

Conclusions
Nepal is a country with a heavy burden of mortality and morbidity from road tra c injuries. The preintervention data showed that tra c police were attending road tra c crashes and transporting casualties with limited or no standardised rst-aid training and limited emergency resources. We were able to develop and design a rst-responder course for the tra c police, focussed on managing traumatic injuries at RTCs. The participants in the training increased their knowledge of rst-aid and their con dence in applying those skills.. They then went on to frequently perform rst-aid at the crash scene.
Essential to the success of this is support from police senior management both nationally and locally. Further studies will need to reinforce the need to capture the use of incident report forms when rst responder skills are applied. The cost of the three day rst responder training course was minimal and the estimated cost of extending the training would compare favourably with the signi cant burden of the direct costs of road tra c injuries in Nepal.
Thus, it is feasible practically and nancially to extend the training to cover other districts/all of Nepal as a low-cost measure to combat road tra c injury in the absence of formal emergency medical services.  Table   Table 6 not available with this version Figures Figure 1