Effects of Participatory Teaching Approach for Red Cross First Aid Trainers of China in 2019: A Before-and-After Study

Red Cross Society of China has always attached importance to training of rst aid trainers. Participatory teaching approach has good effect and great signicance all over the world. Thus this methodology was introduced from International Federation of Red Cross and Red Crescent Societies to China from 2019. This study aimed to investigate effects of participatory teaching approach in training rst aid trainers from provincial branches of China. We conducted a cross-sectional study among rst aid trainers from Red Cross provincial branches. Pretested electronic questionnaire was given before and after the training. Data was collected by online survey tool and logic check was set to ensure quality of data. Stata version 11.0 was used to analyze the data. Proportion were used to describe social-demographic characteristics of respondents and their satisfaction with different teaching modules. Paired two-tailed t-test was used to compare the condence scores before and after training. Chi-square test was used to test condence growth of different groups and among different developing level regions. Difference was statistically signicant if P<0.05. developing level regions. This teaching approach could improve the condence of participants. It is reasonable to promote this methodology among rst aid trainers nationwide.


Introduction
First aid training is one of the statutory duty and key priority of Red Cross Society of China(RCSC). According to our annual statistics, over 3 million rst aider were trained each year. Now RCSC has more than 20 thousand rst aid trainers nationwide. These specialized trainers play an vital role in rst aid training, which directly determine the quality of training. Thus, RCSC has always emphasized the construction of trainer cultivating system. RCSC applied for 'International First Aid Attestation(IFAA)' from International Federation of Red Cross and Red Crescent Societies(IFRC) in 2019 aimed to set higher course standard and continue to improve rst aid training quality. IFAA request the trainers to use participatory teaching approach in rst aid education and teach rst aid technology which is consistent with International First Aid and Resuscitation Guideline 2016 [1]. RCSC had translated the guideline into Chinese and developed textbooks in accordance with the guideline. The textbooks and Chinese version guideline were distributed throughout the whole country. RCSC also asked all the branches to conduct rst aid training under 'four unify' principle, which include uni ed syllabus, uni ed technology standard, uni ed assessment standard and uni ed certi cate. All these work foundation lead to the success of obtaining IFAA in September 2019.
The original course for rst aider included Cardiopulmonary Resuscitation, Trauma Rescue, Accidental Injury and Disaster. IFRC certi cated rst aider course includes the same contents as the original course except using the participatory teaching approach. Thus RCSC needs to promote this new methodology while disseminate rst aid knowledge to the public.
Participatory teaching approach is a mature teaching approach introduced to China from the late 20th century. By using scene simulation and other participatory activities, this approach takes learners as the center of class and encourage learners to fully participate in the entire teaching process. The aim is to enable learners to deeply understand and master rst aid knowledge and skills they have learned and apply them to future social practice exibly.
At present, the research on participatory teaching is still in its infancy. There are very few research achievements, especially when combining with the real situation and speci c subject. RCSC used to pay more attention to rst aid knowledge and skill, but pay no su cient attention to teaching techniques. Now we begin to combine the new approach with rst aid training and designed a study to see whether rst aid trainers can accept this new approach and are willing to apply it in their future training. So we conducted IFRC standard course for trainers using participatory approach in all 34 provincial branches, and surveyed all the participants' attitude towards this course. Hopefully, the result of this study can support policy makers to promote better rst aid training in the future.

Ethics Statement
Ethics committee of Chinese Red Cross National Training Center(CRCNTC)had approved this study. Respondents' written informed consents were obtained by administrative staff of provincial branches who had been trained about the ethics requirement. All questionnaires were completed by the respondents themselves to ensure the reliability. Professional staff check the data daily to control the quality and keep the database con dential and anonymous.All methods were carried out in accordance with relevant guidelines and regulations.

Study Design And Settings
This survey was a cross-sectional,institution-based and before-and-after study which was conducted in 34 provincial RCSC branches including Hong Kong and Macau. Participants were all registered rst aid trainers who nished this participatory standard course. Questionnaires were given to them both before and after the course to identify their attitude towards the training.

Data Collection Tools And Procedures
This study was a census which covered all the rst aid trainers attended this course. Professional staff of RCNTC designed a structured questionnaire and pretested it. The questionnaire includes three parts. The rst part of the questionnaire is about the basic social-demographic characteristics such as sex, age, ethnic, education, major, teaching experience, etc. The second part is about scoring the whole course and every module of this standard course to identify respondents' satisfaction. The third part has four questions related to respondents' con dence that was used to assess rst aid trainers' con dence growth. The questions are mainly from IFRC standard 'Trainer of trainers' textbook.
Researchers of RCSC translated and adjusted the questions according to the local context and the literatures review result to make sure respondents can understand the questions and the Chinese version was translated back into English to ensure consistency. The questionnaire was pretested on 82 senior rst aid trainers from different provincial branches before this survey formally started.
Electronic online survey tool(Wenjuanxing, Changsha Ranxing Information Technology Co., Ltd., Changsha, China) was used to generate a two-dimensional code and set logic quality check to make sure the nished questionnaires was lled and corrected. Participants scanned the QR code of the electronic questionnaire and nish all the questions, then the data was collected and stored automatically behind the scenes. Data was checked daily to ensure the reliability.
Database could be exported to regular EXCEL format which can be analyzed by specialized statistical software such as Stata version11.0.

Statistical Analysis
The exported database had been checked and cleaned thoroughly by the online tool. Then the database was transported into Stata version 11.0 for further analysis. Count and proportion were used to describe social-demographic characteristics of respondents and their satisfaction with different teaching modules. Mean and standard deviation were used to describe the quantitative variables. Four point Likert scale was used to identify respondents' attitude towards each module. Paired two-tailed t-test was used to compare the con dence scores before and after training. Chisquare test was used to test con dence growth of different groups and among different developing level regions.
Difference was statistically signi cant if P < 0.05.

Social-demographic Characteristics of Respondents
The study surveyed 775 trainers and 772(99.6%) of them responded, which included 473(61.27%) female. The minimum and the maximum age of them were 20 and 69 years respectively. The mean age of them was 40.26 with a standard deviation of 8.67. Han Chinese took the most proportion(86.66%). 589(76.29%) respondents had a Bachelor's degree or above.Most of the respondents (62.69%) had medicine related professional background. The majority of the respondents (87.82%) had taught rst aiders before and 82.64% of them taught both theoretical and practical courses.
About half of the participants had less than 3-year teaching experience and about one third of them had 4 to 10 years experience while the others had taught for more than 10 years. Their major target learners were from commercial or workplace. Almost all the respondents didn't take rst aid training as primary source of income (Table 1). Respondents were asked to score their satisfaction with the course from 1 to 10 to represent their satisfaction degree from lowest to highest. The average score was (9.01 ± 1.40).694(89.9%) respondents scored 8 and above, which revealed most of the respondents were satis ed with this training.
This standard course was designed by IFRC. It included 15 modules which were highly relevant to rst aid technology and participatory teaching approach. Four point Likert scale including strongly agree, agree for positive attitude and disagree, strongly disagree for negative attitude was used to nd respondents attitude towards each module. According to the result, the three most satisfying modules were The Red Cross, Course re ection and Adult Learners. And the three least satisfying modules were Course Accommodations, Con ict Resolution and One-On-One Feedback( Table 2).  (Table 3). Respondents were grouped according to the original con dence score they gave themselves before the training.
Respondents who scored themselves 1 to 3 were low con dence group. Those who scored themselves 4 to 6 were medium con dence group. Those scored themselves 7 to 9 were high con dence group. The score they gave themselves after the training was analyzed to identify if the growth was different among 3 groups. Data showed median con dence group had the maximum growth while high con dence group had the minimum. Difference was statistically signi cant (Table 4). Add all the scores of 4 questions together to generate total con dence score before and after the course. The minimum and the maximum were both 4 and 36. The mean score before training was 24.37 with a standard deviation of 7.55.
And the mean score after training was 30.57 with a standard deviation of 5.73. Both before and after course total score were divided into groups: 22 and below, 23 to 29, 30 and above.
Provinces were grouped into East(highly developed areas), Middle(Moderately developed areas) and West(Less developed areas) according to classi cation standard of Communiqué on the Main Data of the First National Economic Census (No. 1) [2]. Total con dence score of trainers from different regions were compared using Chi-square test. No statistical signi cant difference was found among regions (Table 5). were 24585 registered Red Cross rst aid trainers till the end of 2018. Also, talent drainage and lack of professional enthusiasm lead to a further loss of trainer. That means more quali ed trainers should be cultivated as soon as possible. Since rst aid education is statutory duty and key priority of Red Cross and Red Crescent movement, years of solid work had good effect in community, school and workplace [5]. We needs to continue with these traditional work, this also requires enough active, capable trainers. Now RCSC doesn't have enough trainers to achieve this goal. We need to establish a stable trainer system.
According to RCSC previous research [4], male and female trainers took similar proportion. The average age was 40.08 ± 8.72. Most of them had medicine related education background and several years of teaching experience. More than 90% of the trainers were part-time and don't take rst aid training as their principle source of income. Also, trainers of Noway take work place as the most common source of training[6], which is similar to our study. All these characteristics were similar with the respondents of this study, which make the respondents of this study representative.
First Aid Course of RCSC Study [7] shows that when immediate assistance is provided within 5 minutes after the accident, the wounded survival rate is 85%, while over 15 minutes it is 72%, and 20 minutes from the event it is 60%. So rst aid plays a crucial role in saving lives and reducing mortality. Lay people can also play an important role in emergencies,but only when they have enough skill, con dence and willingness to provide assistance [8].
Although there may exist some bias stop researchers from nding out which population may bene t most from rst aid training [9], it is certain rst aid course can be very effective among different population.Traditional rst aid course emphasized mainly on Cardiopulmonary Resuscitation, Trauma Rescue, Accidental Injury and Disaster Rescue.What is most important about rst aid education is constructing learners' con dence so they will be willing to help others in future emergency. Some researchers tried to add new content such as psychological rst aid, but no overall signi cant differences were found for learners' con dence [10]. Since learners' theoretical rst aid knowledge was worse than expected[8], efforts should be made to transform the theoretical training into the practical training [11] and add new teaching tools [12]. Interactive activities which allow learners to explore and discuss can effectively increase their willingness and con dence to help once they are in an emergency [13,14]. New teaching approach such as peereducation and scenario-based approach were experimented, the result showed participation in a rst aid training improved self-e cacy [15,16]. First aid programs that prepare learners to overcome inhibitors in emergency could lead to better help and higher helping rates [17,18].

Effect of Participatory Teaching Approach in Teaching First Aid Trainers
In order to continuous improve the training quality and give learners an appealing experience, RCSC brought in a standard IFRC trainer curriculum using participatory teaching approach from 2019. This curriculum includes practical training, peer-education and scenario-based activities, which may be an important complement to rst aid knowledge and skills.Our curriculum was designed with reference to IFRC standard 'Trainer of Trainers' textbook included 15 standard modules and adjusted according to biology of learning and teaching [19]. All the modules should include at least an energizer, formal lecture and participating activities to transfer education and rst aid knowledge to the trainees.The aim of this curriculum was to immerse trainees in a participative environment, to learn both knowledge and pedagogy, and to expect them to apply participative approach into future rst aid education.
First Aid education needs more practice than just theory [20]. Participatory teaching approach is a learner-centered, scenario-simulated and various teaching resources-motivated approach which gives learner good learning experience. This approach had been proved useful in some population like medical student [21,22] and some subject [23]. We assumed this approach might help the learners to immerse themselves in speci c trauma/respiratory arrest and cardiac arrest situation and apply their knowledge and technology to save people's life. And we had completed a research [24] in 2019 which showed the rst batch of 82 senior trainers trained by participatory approach were satis ed and had con dence growth after the training. So we do this further research to nd out whether it is feasible to promote this course on a wider scale.

Effectiveness of IFRC Trainer Course
There are 4 questions covering four different dimensions of con dence. All the self-scoring had increased signi cantly.
Respondents were more con dent in being a quali ed trainer than supporting quality management of a psychologically safe learning environment and evaluating learning outcomes. According to Table 1, the average scores of Question 1, 2 and 4 increase more than Question 3, possible reason is that the trainer management and continuous evaluation have long been a Red Cross rst aid training focus content. But maintaining a safe psychological learning environment is relative less mentioned. The IFRC 2016 guideline focuses on "First Aid education", thus in the future we may add highly relevant theories such as participatory teaching and psychological learning environment in rst aid education.
Respondents had varied self-scoring before the course in all 4 questions, but different con dence group all had statistically signi cant con dence growth. Median con dence group had more growth than low con dence group and high con dence group. But the increasing range was not as much as the previous research among 82 senior trainers [24]. Canadian Red Cross found signi cant heterogeneity in learner outcomes varied by different provinces [25]. We found respondents with different baseline con dence had different con dence increase, but we didn't nd region heterogeneity in our study. Thus it is proper to promote this course in our country.
There are 15 standard modules in the course.The Red Cross, Course re ection and Adult Learners are the 3 most satisfying modules. In traditional rst aid training, The Red Cross is a conventional popular session which distinguish red cross rst aid training from other commercial training. But there used to be no re ection. Since this is also a bene cial teaching approach [26] and is well accepted among rst aid trainers, we should emphasize this part in future rst aid training. Adult learners have different characteristics comparing with children [27]. The 2016 IFRC Guideline requires national red cross society to create educational programmes for children and adult, according to their cognitive, social and behavioural abilities. It is suggested that we should attach importance to the teaching of adult learner and develop courses for different populations to achieve good rst aid training effect.

Conclusion
This study highlights the satisfaction and con dence growth of Red Cross rst aid trainers from provincial branches after a standard participatory curriculum. And no statistically signi cant was found among different developing level regions. We hope this study may provide useful information to policy-maker, and supporting their decision of promoting this participatory course among rst aid trainers nationwide. Further research needs to be considered to con rm the validity of participatory approach in teaching not only rst aid trainers but also rst aiders. Correspondence and requests for supporting materials should be addressed to J Zhao.

Financial Disclosure
The author(s) received no speci c funding for this work. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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