Evidence-based educational pathway and teaching materials for first aid training of children in Sub-Saharan Africa

Background First aid training is a cost-effective way to decrease the burden of disease and injury in low- and middle-income countries (LMIC). Since evidence from Western countries has shown that children are able to learn first aid, first aid training of children in LMIC may be a promising way forward. Hence, our project aim was to develop evidence-based contextualized materials to train Sub-Saharan African children in first aid. Methods Systematic literature searches were conducted to identify studies on first aid education to children up to 18 years old (research question one), and studies investigating different teaching approaches (broader than first aid) in LMIC (research question two). A multidisciplinary expert panel translated the evidence to the context of Sub-Saharan Africa, and evidence and expert input were used to develop teaching materials. Results For question one, we identified 58 studies, measuring the effect of training children in resuscitation, first aid for skin wounds, poisoning etc. For question two, two systematic reviews were included from which we selected 36 studies, revealing the effectiveness of several pedagogical methods, such as problem-solving instruction and small-group instruction. Expert input was useful for placing the evidence against the African context. Conclusions The above approach resulted in an educational pathway (i.e. a scheme educational goals age a list recommended educational approaches, and teaching context.


Background
In Sub-Saharan Africa, approximately 5·1 million deaths each year are attributable to conditions that could have potentially been addressed by prehospital and emergency care 3 [1], which is however underdeveloped in the majority of low-and middle-income countries (LMIC) [2,3]. Hence, first aid training is promoted by the World Bank as a very costeffective way to decrease the burden of disease and injury, with a cost of only 8 USD per disability-adjusted life year averted [1]. Although most studies demonstrating the effectiveness of first aid training programmes for adults were conducted in Western contexts [4][5][6][7][8], some studies from Sub-Saharan Africa are also available [9][10][11], and several African Red Cross National Societies organize first aid trainings for adult laypeople. These trainings were mostly based on materials from Western former colonisers (e.g. the UK, France), which provided a useful basis, but did not take into account the distinct African context, which was expressed as a need by the local Red Cross National Societies [2]. In an attempt to meet these needs, contextualized and evidence-based African First Aid Materials (AFAM) have been developed, providing up-to-date first aid techniques, as well as injury and disease prevention advice specific for the African context [2].
Since emerging evidence from Western countries has shown that children and adolescents from 5 to 18 years old are able to learn certain first aid techniques and are willing to provide help [12][13][14][15][16][17], first aid training of children seems a promising way forward in order to maximize impact. To support the development of materials to train children in first aid, and to facilitate the integration of first aid training into the school curriculum, an educational pathway may be a useful tool. An educational pathway is an instrument that indicates how children can achieve necessary competences over a certain period of time.
Within the pathway basic facts of a topic are taught first, and complexity gradually increases as the child's age and learning progresses. Reemphasis helps to reinforce and solidify the learning content, so that it can enter the learner's long-term memory. In the field of first aid, such repetition could help to automate actions, so that learners no longer 4 have to think about each step during stressful first aid situations.
In addition to the importance of the child's age, the teaching strategy used during the first aid training also affects the child's knowledge, skills, and attitude. Evidence-based education research, based on many meta-analyses, has shown that classroom methods such as cooperative learning, and feedback or problem-solving methods are effective educational methods that improve learning [18,19]. However, the evidence base mainly consists of Western studies, and less is known about effective educational methods in LMIC.
As contextualized first aid materials for children are currently non-existent in Sub-Saharan Africa, the aims of this project were: (1) to develop an evidence-based educational pathway for first aid training to children (5-18 years) in Sub-Saharan Africa, and (2) to create an overview of evidence-based effective educational methods in the Sub-Saharan African context. This resulted in teaching materials for first aid training of Sub-Saharan African children.

Methods
To provide a basis for the educational pathway and teaching materials, several systematic literature searches were performed. The reporting of the systematic literature reviews was done according to the PRISMA statements (Additional File 1) [20]. No protocol for the systematic literature searches was published beforehand.

Systematic literature searches and study selection
Our first research question concerned the effectiveness of first aid education to children of different age groups, on first aid knowledge, skills, and attitude. A similar and previously published systematic review (search date: 2012) was used as a basis for the current searches [12]. New first aid topics were added and selection criteria were adapted to the African context (e.g. training on the use of an automated external defibrillator was not included due to limited resource availability).
Several parallel literature searches were performed for each of the different first aid topics mentioned above (except for 'disaster principles', for which decisions were based on consensus only), either by updating the existing literature searches (publication date between previous search dates (January 2012) (12) and the current search date (March 23 2017)) or by developing new search strategies for new topics. All searches were run in two databases (MEDLINE and Embase). Search strategies and selection criteria can be found in Additional files 2 and 3, respectively.
Our second research question concerned the effectiveness of different educational approaches on children's knowledge, skills, and attitude in LMIC. Instead of focusing on first aid education, we broadened this research question to education in general. We searched for existing systematic reviews published between 2012 and 2017 (The Campbell Library, MEDLINE, Embase, ERIC and the 3ie Database of Systematic Reviews), since we only wanted to include the most recent educational approaches. Search strategies and selection criteria can be found in Additional files 4 and 5, respectively. The scope of the educational interventions of interest was narrowed to three categories: (1) the provision of traditional hardware instructional materials (e.g. text books, flip-charts), (2) use of 'structured pedagogy interventions' (i.e. a combination of newly developed structured 6 lesson content and teacher training in delivering such materials, whether or not in combination with teacher and/or student materials), and (3) use of alternative pedagogical methods (e.g. cooperative teaching, constructivist-based teaching, problem-solving method of teaching). Study selection was done by a single reviewer for both research questions, based on title and abstract, and subsequently based on full text.

Data extraction, data synthesis and quality assessment
For both research questions, the following data were extracted by a single reviewer: study design; characteristics of the population (number of participants, age range); characteristics of the specific programmes (content, duration); methods of outcome measurement; means, mean differences (MDs), and confidence intervals (CIs) for continuous data, and risks, risk ratios (RRs), and CIs for dichotomous data. In addition, a risk of bias assessment of all individual studies, and an assessment of the overall certainty of evidence (per outcome for question one, and per intervention for question two) was performed using the GRADE approach [21]. For research question one, the evidence was synthesized in a narrative way, because meta-analysis was not possible due to heterogeneity at population, intervention and outcome level. For research question two, effect sizes were extracted from the meta-analyses performed in the identified systematic reviews. Red Cross National Societies, as well as academic educational experts and clinicians from Sub-Saharan origin (French and English speaking countries), and chaired by HG, was gathered for consultation in Johannesburg, South Africa (November 17-18 2017). Before the start of the meeting, the draft educational pathway and specific preparatory questions were sent to the panel members. The goal of the meeting was two-fold: (1) to collect feedback to adapt the educational pathway to the local context, and to reach consensus on the final pathway; and (2) to compile a list of effective educational approaches for children, tailored to the Sub-Saharan context. More details on how consensus was reached to achieve these goals can be found in Additional file 6.

Development of evidence-based teaching materials
In a last phase, teaching materials were developed, taking into account: (1) the educational pathway, showing which first aid competences can be achieved at a certain age, (2) the list of effective educational methods, and (3) the content of the evidencebased AFAM, which was updated in 2016 (i.e. the specific first aid interventions) [2].
These teaching materials were circulated electronically for feedback from the expert panel, and a final conference call was organized to discuss this feedback and validate the materials in November 2018.

Study identification and study characteristics
For research question one, 58 studies were identified (see figure 1). Of these, 43% (25 studies) was performed in Europe, whereas only 4% (two studies) were conducted in Africa. The topic of 'resuscitation' was very well covered. For the other first aid topics, evidence was scarce or even non-existent. Detailed characteristics of the 58 included studies are listed in Additional file 7.
For research question two, 819 references were screened and finally two systematic reviews were included (see figure 2). The first systematic review included 238 (quasi-)experimental studies, conducted in LMIC, studying a large range of interventions aimed at improving school enrolment, attendance, drop-out, completion and learning as primary outcomes [22]. Of interest to our research question were four studies looking at the provision of instructional materials (e.g. textbooks, flip-charts), and 19 studies investigating structured pedagogy interventions (as defined above). The second systematic review was a PhD thesis of 66 (quasi-)experimental studies, conducted in Sub-Saharan Africa, that looked at the same interventions as listed above, as well as interventions focused on improving repetition and retention rates [23]. Of these, we included 16 studies on the use of alternative pedagogical methods, of which three were also included in the category of structured pedagogy interventions. Detailed study 9 characteristics are presented in Additional file 8.

Best available evidence on the effectiveness of first aid training to children
In the paragraphs below, the findings concerning the effectiveness of first aid training interventions for 'burns', 'bleeding', and 'skin wounds' are discussed in detail. The detailed findings on the other first aid topics, as well as the risk of bias and certainty of evidence, can be consulted in Additional file 7.
In total, we identified six studies that included burns in their training programme (see Table 1 for study characteristics, and Table 2 for study findings) [24][25][26][27][28][29]. A statistically significant increase in first aid knowledge was shown after attending a first aid training course, compared to the baseline situation or control group without training, in children of 19.80, p<0·001, immediately after the course; RR: 20.00, p<0.001, after two months follow-up) [29]. Two studies also measured the children's skills, by providing an audiorecorded scenario with a severe burn injury in a toddler or a description of a situation requiring first aid for burns [24,29]. In a pre-post study with 11-to 15-year-olds, a significant increase in first aid skills was found (RR: 189.00, p<0·001, immediately after training; RR: 149.00, p<0·001, after two months follow-up) [29]. However, in a study with 11-to 16-year-olds that used a placebo training (on tobacco and alcohol prevention) as a control, no increase in skills concerning the order of first aid responses and listing the  [24].
Three studies reported on the effectiveness of first aid training concerning bleeding and skin wounds [24,28,29]. A statistically significant increase of knowledge concerning first aid for bleeding or skin wounds was found in children of 11 years onwards. The study by year-olds showed a significant improvement in skills concerning the order of first aid responses in case of bleeding or skin wounds, but not in listing the correct procedures [24]. The certainty of the evidence was very low for the three topics.
[ Table 1 and Table 2 should appear somewhere in paragraph 3.2]

Best available evidence on the effectiveness of educational interventions in LMIC
We identified four studies on the provision of instructional materials to primary schools or In total, 17 (quasi-)experimental studies provided 41 effect sizes on using alternative pedagogical methods on learning or testing outcomes of students attending primary or secondary schools across seven African countries (Nigeria, Kenya, Ghana, South Africa, Uganda, Liberia and Mali) [23]. Compared to the use of conventional teaching methods (mostly lecturing), the use of alternative pedagogical methods, such as problem-solving instruction, small-group instruction, guided-inquiry instruction, cooperative instruction and constructivist instruction, was shown to significantly increase the students' learning Study findings are provided in Table 3, whereas study characteristics and determination of the certainty of evidence can be found in Additional file 8.
[ Table 3 should appear here]

Educational pathway on first aid for Sub-Saharan Africa
The best available evidence on the effectiveness of first aid training to children was used to draft the educational pathway, which was then discussed with the expert panel for context adaptation. An example of how the pathway was adapted to the African context deals with seeking help from a medical care provider. In the draft pathway, it was proposed that children should know how to seek help from a medical care provider at the age of 7-8 years. Since medical care is less accessible in Africa than in Western countries, the expert panel decided to postpone this to the age of 9-10 years, and to keep on repeating until the age of 18 years. A second example deals with the general first aid 12 competence of handwashing before and after administering first aid. Because of the higher prevalence of infectious diseases in the African context, the panel proposed to repeatedly train children until the age of 18 years.
For the topic of burns, evidence showed that children of 6-7 years old can be taught how to correctly provide first aid [27]. The expert panel extrapolated the evidence on burns knowledge in a consistent way to the topics of bleeding and skin wounds, since evidence on the latter topics for children under 11 years was lacking, hence concluding that children should have acquired the basic knowledge at the age of 7-8 years. More advanced knowledge should be attained at the age of 11-12 years (e.g. children know the link between tetanus and skin wounds), or at the age of 13-14 years (e.g. children know the different types of burns). Based on the opinion of the experts, only one knowledge item should already be acquired at the age of 5-6 years: the most common causes of burns (i.e. hot water, fire, flames). Skills competences were set in accordance with the knowledge items.
The final version of the pathway can be found in Table 4 (for the topics 'burns', 'bleeding', and 'skin wounds') and Additional file 9 (for all topics).
[ Table 4 should appear here]

Teaching materials for first aid training to children in Sub-Saharan Africa
The panel members agreed to cluster the 2-year age ranges of the educational pathway into 3 broader age groups for the development of separate teaching materials (5-8 years old, 9-12 years old and 13-18 years old). Also, they agreed on a number of recommended educational methods, applicable to the African context. An overview of these methods, the age groups for which they are (most) appropriate, as well as their strengths and 13 weaknesses, is presented in Table 5. The top three of most appropriate and successful teaching methods for each age group is presented in figure 3. Text messaging and the use of individual worksheets for children were perceived as non-feasible or non-desirable educational methods.
[ Table 5 should appear here] Following the panel meeting, evidence-based teaching materials were developed for the age group of 9-to 12-year-olds, incorporating the recommended teaching methods for this age group. The competencies to be achieved when following a training using these materials were based on the content of the educational pathway, again for this specific age group.

Discussion
Our evidence-based educational pathway on first aid links key learning objectives concerning first aid to a child's specific age range (see Additional file 9). It denominates which topics can be covered when training children in first aid, visualizes the time points at which certain items should receive attention, and it is adapted to the African context. Besides its strengths, our project also has several limitations. First, only two databases were searched for evidence on first aid training of children, because of feasibility reasons.
However, we believe these databases are most relevant to this study subject. Second, for 14 several first aid topics, including 'skin wounds', 'burns', 'bleeding', 'injuries to bones, muscles or joints', and 'poisoning', a very limited amount of evidence or no evidence was found. Therefore, many gaps had to be filled by the expert panel, based on their expertise and consensus. In addition, almost half of the studies were European studies, and only four African studies are currently included in the evidence base. Third, the quality of the obtained evidence was in many cases very low. This is mainly due to the study designs that are typically used to study educational programme effectiveness, including many uncontrolled before-after studies. There was also a high degree of heterogeneity between the studies, especially at the intervention level (with many differences in the content, delivery and duration of the training programme), and outcome level (measured in many different ways and at different time points).
Nevertheless, this project has several important implications for practice. First, the educational pathway on first aid can be used by first aid trainers to help them decide which content to teach to children of certain age ranges. Second, the educational pathway may be a useful tool for advocating the importance of first aid in health education with the Ministry of Health/Ministry of Education of Sub-Saharan African countries. In Zimbabwe, it was recently decided by law to integrate first aid education in the school curriculum. Third, the evidence on the effectiveness of first aid training to children (Additional file 7), which is independent of any geographical region, can be used to develop similar first aid educational pathways, and accompanying training materials, for other contexts or countries.
Since we identified several gaps in research, we also want to advocate for higher quality future research, that use appropriate control groups, on the effectiveness of first aid training to children in different geographical regions on several learning outcomes. This will allow further development of improved first aid materials. 15

Conclusions
The available evidence we identified, together with input from a multidisciplinary expert panel, was used as a basis to develop an evidence-based educational pathway for first aid training of Sub-Saharan African children (5-18 years), and to create an overview of evidence-based effective educational methods in the Sub-Saharan African context. The educational pathway shows which educational goals can be achieved within specific age groups, and represents a useful tool to design a first aid curriculum for children. Both the pathway and the overview of educational methods were used to develop evidence-based teaching materials for first aid training of children in Sub-Saharan Africa. These materials were piloted in Zimbabwe and will soon be implemented in several African countries.

Availability of data and materials
All data generated or analysed during this study are included in this published article and its supplementary information files.    SMD: standardized mean difference, SE: standard error † Imprecision (lack of data): mean of the control group is not reported † † Imprecision (lack of data): total sample size is not reported   Figure 1 PRISMA study selection flowchart for research question one.

Competing interests
36 Figure 2 PRISMA study selection flowchart for research question two.
37 Figure 3 Top three of most appropriate and successful teaching methods for each age group.

Supplementary Files
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