“Calling for help, performing first aid and providing Cardiopulmonary Resuscitation (CPR)” is part of the educational goals in secondary schools in Belgium (Flanders). However, for teachers it is not always clear at what age children can be taught which aspects of first aid. In addition, it is not clear what constitutes “performing first aid” and we strongly advocate that the first aid curriculum is broader than CPR training alone.
To develop an evidence-based educational pathway to enable the integration of first aid into the school curriculum by defining the goals to be achieved for knowledge, skills and attitudes, for different age groups.
Studies were identified through electronic databases research (The Cochrane Library, MEDLINE, Embase). We included studies on first aid education for children and adolescents up to 18 years old. A multidisciplinary expert panel formulated their practice experience and expert opinion and discussed the available evidence.
We identified 5822 references and finally retained 30 studies (13 experimental and 17 observational studies), including studies concerning emergency call (7 studies), cardiopulmonary resuscitation (18 studies), AED (Automated External Defibrillator) use (6 studies), recovery position (5 studies), choking (2 studies), injuries (5 studies), and poisoning (2 studies). Recommendations (educational goals) were derived after carefully discussing the currently available evidence in the literature and balancing the skills and attitudes of children of different ages.
An evidence-based educational pathway with educational goals concerning learning first aid for each age group was developed. This educational pathway can be used for the integration of first aid training in school curricula.
Bystanders can play a vital role in delivering help in case of a sudden injury or illness, before professional help arrives, and first aid training is a way to improve this initial response by laypeople.
The frequency of first aid given by laypeople to trauma casualties worldwide ranges from 10.7% to 65%, and incorrect first aid is being given in up to 83.7% of the cases, according to a systematic review including 10 studies from all over the world.1 In a 2013 USA survey it was shown that only 20% of laypeople knew about hands-only CPR, while 75% would be willing to perform it.2 More specifically in Belgium, a population-based survey in 2011 showed that only 39% of the participants would start resuscitating in case a casualty would collapse, and less than 50% of the participants knew what the function of an AED (Automated External Defibrillator) was.3 Therefore, wider dissemination of first aid training might effectively increase the proportion of bystanders likely to perform first aid.
In a recent study it was shown that instructing schoolchildren to teach CPR to their relatives and friends results in a more positive attitude towards bystander CPR.4 Currently in Flanders (Belgium), “calling for help, performing first aid and performing CPR” is part of the educational goals in secondary schools. However, for teachers it is not always clear at what age children can learn the different aspects of resuscitation, AED use and/or other aspects regarding first aid, and teachers often feel uncomfortable in teaching this matter.4,5 In addition, it is not clear what is part of “performing first aid” and we strongly advocate that the first aid curriculum is defined more broadly than CPR training alone. Therefore, the aim of this project was to develop evidence-based an educational pathway to enable first aid to be integrated into primary and secondary education, by defining the goals to be achieved for knowledge, skills and attitudes.
An evidence-based educational pathway was developed based on evidence identified in systematic literature searches and practice experience of a multidisciplinary expert panel, according to our methodological charter and the principles of AGREE II.6,7 The reporting of the systematic literature reviews was done according to the PRISMA statements (PRISMA checklist see Supplementary material, Appendix 1).8 No protocol for the systematic literature searches was published beforehand.
2.1. Selection of educational pathway content
The following 12 topics were selected: calling the emergency number, resuscitation, AED use, choking, Rautek technique (emergency removal of a casualty that is in danger, whereby the casualty is dragged backwards), placing a victim in recovery position, cuts and grazes, burns, bleeding, fainting, injuries to muscles/joints/bones and poisoning. The PICO question can be formulated as follows: Is first aid education (related to one of the above topics) (Intervention) an effective intervention in children (3–18 years) (Population) to improve first aid knowledge, first aid skills and/or first aid attitudes (Outcome) compared to no first aid training (Comparison)? In addition, we searched for evidence about the helping behaviour of children.
2.2. Systematic literature search
2.2.1. Search strategy
Since this project was initially started (in 2012) with the intention of developing evidence-based first aid manuals for children (with only a limited number of topics included), and in a second phase (in 2014) was extended to develop evidence-based educational materials (with a broader scope and more extensive number of topics relevant for schools), we performed searches on two separate moments. However, if the included papers for the second set of questions also included relevant data for the first set of topics, these data were also extracted. We searched Medline (PubMed interface) and Embase (Embase.com) from the date of inception until 10/01/2012 for a first set of questions (emergency number, resuscitation, AED use, choking, Rautek, recovery position, and helping behaviour) and until 25/03/2014 for a second set of questions (cuts and grazes, burns, bleeding, fainting, injuries to muscles/joints/bones and poisoning). The search strategy can be found in the Supplementary material (Appendix 2). Study selection was performed by one reviewer. Titles and abstracts of the references identified by the search were scanned. When a relevant article was found, full texts were retrieved, and studies meeting the selection criteria were included. The citation and reference lists of included studies were searched, and the first 20 related items in PubMed were scanned for other potentially relevant studies.
2.2.2. Selection criteria
We used the following inclusion and exclusion criteria for selection of articles:
Population: We included studies with children or adolescents up to 18 years old. Children with disabilities were excluded.
Intervention: We included studies on first aid education concerning the topics described above. Studies where (part of) the training was given at the hospital were also included. Since AEDs have been developed to be used without formal training, studies on AED use by children were also included even if no training was provided. Studies on helping behaviour were also included if no training was provided, since our aim was to have an overview of current (barriers influencing) helping behaviour. Studies evaluating online training only were excluded.
Control: We included studies with a control group or baseline measurement, or comparing different age groups. Studies on AED use and helping behaviour were also included even if no control group or baseline measurement was included.
Outcome: We included studies that measured first aid knowledge, skills, attitudes, or (factors influencing) helping behaviour.
Study design: We included (randomized) controlled trials, (controlled) before and after studies, case-control studies and cohort studies. For studies on AED use and helping behaviour, we also included cross-sectional studies and case series. We excluded conference abstracts.
Language: We only included studies in English.
2.2.3. Data extraction
Data concerning study design, study population, outcomes, effect measures (expressed as risk ratio, odds ratio, or mean/median differences), and study quality were extracted by one reviewer. Review Manager 5 was used to calculate effect measures, if not reported in the study and if possible. The GRADE approach was used to assess the overall quality of evidence (going from high to very low) included in these guidelines. According to GRADE, the initial level of evidence is high for experimental studies and low for observational studies. The level of evidence was further downgraded because of limitations in study design (risk of bias), inconsistency, indirectness, imprecision or publication bias. Limitations in study design were analysed at the study level using the items listed by GRADE.9
2.3. Formulation of evidence-based recommendations
We composed a multidisciplinary expert panel of primary and secondary school teachers, educational advisers, experts in first aid education (including Red Cross employees and volunteers), an expert in health promotion, experts in evidence-based practice, a medical doctor and a child psychologist. We held two consensus meetings (1/02/2012 and 6/05/2014) with the same expert panel. During the first meeting a short training in Evidence-Based Practice was given and a first set of PICO questions was presented and discussed. During the second meeting, a second set of PICO questions and the draft educational pathway (prepared by the Red Cross Youth and First Aid Department) was presented. Where evidence was lacking and consensus was reached about “good practice”, “Good Practice Points” were formulated. Consensus was reached about the educational pathway, using informal consensus methods. The final version of the educational pathway was finally approved by all panel members.
3.1. Study identification
We retrieved 5822 references in total, and 30 studies were finally retained as a basis for the recommendations in the guideline (see Fig. 1 for study selection flowchart). A list of the excluded studies with their reason for exclusion can be found in the Supplementary material (Appendix 3). The major reason for exclusion was study design (56%) as many studies did not include a control group or performed a baseline measurement, or references were references were opinion pieces, letters, or comments.
PRISMA flowchart of identification and selection of studies.
The 30 studies finally retained include 15 European studies (Austria, Norway, Spain, UK),10,11,12,13,14,15,16,17,18,19,20,21,22,23,24 7 studies from the USA,25,26,27,28,29,30,31 3 studies from Australasia (Australia and New-Zealand),32,33,34 2 African studies (Egypt and Zambia),35,36 and 3 Asian studies (Japan, Pakistan, India).37,38,39 Only for Rautek and fainting, no evidence could be identified. The 30 studies included 13 experimental studies and 17 observational studies (see Table 1). Detailed characteristics of the included studies are given in Table 1 and Appendix 4 (Supplementary material).
Table 1Characteristics of included studies for evidence review concerning helping behaviour, emergency call, choking and recovery position.
Number of participants:228 children (126 boys, 102 girls); intervention:n = 117, control: n = 111
Age: 6–7 years
Program: theoretical and practical first aid/CPR training given by first aid instructors of the Norwegian Red Cross using a glove puppet
Content: the body and its functions, assessment of consciousness and breathing, wound treatment, bleeding, recovery position, behaviour in emergency situations, emergency call, first aid scenarios
Duration: 5 lessons (45 min each, one lesson a week)
Control: no training
Outcomes were measured immediately and 6 months after the intervention:
Knowledge: knowledge emergency number (measured in test scenario described below)
Skills: measured in a test scenario where first aid should be given to an unconscious victim after a cycle accident; the following items were evaluated: correct assessment of consciousness/breathing; giving correct emergency information; correct recovery position; correct airway management
Number of participants:660 children (51% boys, 49% girls); intervention:n = 293, control: n = 367
Age: 11–16 years
Program: first aid and home safety training, led by 23 trained group leaders (derived from American Red Cross training courses)
Content: focus on responding to emergency situations (first aid) and on prevention of injuries: emergency care, fever and first aid kit, controlling bleeding and treating burns, fractures, dislocations and sudden illness, sport injury and prevention, poisoning, bites, stings and allergies, first aid review and household safety
8 educational sessions (2 h each) over a 7-to-10 week period.
Session format (welcome and session overview, check-in, brief review of previous session, group leader lecture presentation, break, skills demonstration and practice, homework assignments, closure)
Program: tobacco and alcohol prevention program, led by 23 trained group leaders
Content: listening skills, communication skills, health effects of smoking and peer pressure, health effects of alcohol and decision making, societal influences and refusal skills.
8 sessions (2 h each) over a 7-to-10 week period
Outcomes that were measured before, immediately and 1 year after the intervention:
Knowledge: the following items were asked for in a survey:
Knowledge of correct emergency response procedures (check-call-care)
Knowledge of items that should be included in a first aid kit
Knowledge of distinct items in the kit
Changes in the availability of a first aid kit at home (attitude)
[these data were not extracted]
Outcomes that were measured before and 1 year after the training:
Attitudes: Response to two audio-recorded
scenarios that involved accident victims (scenario 1: respond to a severe wound from glass; scenario 2: respond to a severe burn injury to a toddler). It was noted if the respondents stated that they would check the scene and victim (response 1), call 911 (response 2), and care for the victim (response 3). If all three responses were given, it was noted if the adolescent listed these three steps in the correct order (i.e., check, call, and care)
Number of participants:79; intervention:n = 46, control: n = 33
Age: 10–12 years
Program: single course of instruction in cardiopulmonary resuscitation (‘ABC for life’ programme)
Content: A session consisted of 4 stages, with the use of cartoons, simple language and memory aids: (1) video, (2) small group teaching, (3) demonstration manikin, (4) supervised practice. The teaching was divided in three parts: approach, CPR, recovery position.
Duration: duration of less than 2 h for each teaching session
Control: no training
Outcomes were measured before, immediately (only intervention group) and 6 months after the intervention:
Knowledge was measured using a 22 point multiple choice questionnaire (8 questions about patient approach)
Number of participants:893 adolescents (50% boys, 50% girls); intervention:n = 741, control: n = 152
Age: 13–14 years
Program: first aid training program ‘Do Something’
-a textbook to teach following topics: get ready for action, obtain an overview of the situation, perform plan ABC (Airway, Breathing and Circulation), give first aid and finish first aid.
-a video containing 7 episodes dealing with chest pain/cardiac arrest, serious epileptic seizure, injuries to the head or neck, burn injuries, internal bleeding, obstruction of the airways and drowning.
Duration: about 6 months
Control: no intervention
Outcomes were measured before and 6 months after the intervention:
Knowledge of first aid was measured via 17 questions (53 items). One score was calculated for each main question. The score for each student ranged from 0 (none of the answers correct) to 100 (all the answers were correct). [these data were not extracted, since no separate data on separate first aid topics were available]
Attitude towards giving first aid was calculated based on 3 questions
Attitude towards learning first aid was calculated based on 3 questions
Number of participants:1292 children; intervention:n = 657, control: n = 635
Age: 10–11 years
Name of the program: Injury Minimization Program for Schools (IMPS)
(1) education resource pack providing teaching materials exploring all aspects of risks and safety of following areas: road safety, accidents in the home, fire, electricity, poisons and waterways.
(2) hospital visit with three learning opportunities: (i) basic life support and resuscitation skills, (ii) interactive video about common accidents (burns, cuts, electrocution, first aid responses), (iii) a tour of an accident and emergency department.
Duration: program is delivered within school curriculum (packs are available during whole academic year).
Control: no training
Outcomes that were measured before and 5 months after the intervention:
Knowledge was tested using a specifically developed quiz, which after coding into categories (correct, incorrect, missing, and not applicable)
produced nominal level data.
Outcomes measured 5 months after the intervention:
Attitude (stopping risky behaviour) was tested with a validated research tool (“draw and write”); a video was shown, depicting an evolving story of a group of children engaged in both subtle and obviously dangerous activities near a canal. Children recorded their observations and further developed the story by drawing and/or writing on a response sheet
Intervention: watching a video about the operation of an AED and 6 video clips with different cardiac arrest scenarios
Outcomes were measured immediately after the intervention:
Attitude: willingness to perform chest compressions, mouth-to-mouth resuscitation and automated external defibrillation, prior knowledge and experiences with CPR and AED and possible reasons for not intervening were evaluated using a 35-item survey
Number of participants:41 children (24 girls, 17 boys)
Age: 11–12 years
Program: CPR training
Content: first a video was shown, showing emergency situations and CPR techniques; instruction in CPR skills was given by a trained teacher using a manikin; a discussion of the ethical and practical issues was held using 4 scenarios where life support techniques were used
Duration: 3 1 h lessons
Outcomes were measured immediately and 9 days (only skills) after the training:
Knowledge was measured using a multiple choice questionnaire
Skills: assessment of practical ability using training manikins and an 11-point checklist
Content: short video and hands-on practice course using a manikin; one lesson discussing the ethics of CPR
Duration: 2 1 h lessons + lesson on ethics (duration not known)
[the data about CPR training from a teacher assisted by an older pupil, were not used in this analysis]
Outcomes were measured immediately after the training:
Knowledge was measured using a 10-point multiple choice questionnaire
Skills: assessment of practical ability using training manikins; an overall score was calculated by counting the individual points for each component of CPR and converting this to a percentage.
Attitude was measured using a questionnaire; a Likert scale was used for some questions, and an open-ended question was also included. An overall score was calculated by counting the individual points on the questions with the Likert scale and converting this to a percentage (’definitely would’ scored 10 points, ‘probably would’ 5 points, ‘probably would not’ 1 point and ‘definitely would not’ 0
Points). This percentage score which was placed into one of four categories (less than 50% ‘unlikely to respond’, 50–69% ‘possibly would’, 70–89% ‘probably would’ and 90% or more ‘very probably would respond’).
Content: CPR training using a DVD, an inflatable manikin, a cardboard phone and an information folder
Duration: 45 min (30 min DVD)
[the data about family members and friends (adults) that were trained at home with children as facilitators, were not used in this analysis]
Outcomes were measured before and 1 week after the training:
Skills were measured using a manikin. The children were told that an adult had collapsed in front of them. Compression depth and tidal volume were measured by a reporting system accompanying the manikin, and other outcomes were registered using video recording. Skills were scored on a scale from 14 (worst) to 56 (best) based on a revised Cardiff test
Number of participants:246 children; intervention:n = 122, control: n = 124
Age: 5–6 years
Program: Safety city program
Content: safety education program about how to cross the street, call 911 in an emergency and avoid strangers; each session consist of a lecture and a practical part (e.g. crossing the street, a board game concerning stranger avoidance, and using a fake telephone); at the end of the course the children receive a coloring book and a rock concert reinforcing the teaching objectives
Duration: approximately 20 min per topic; half-day course
Control: no training
Outcomes were measured before and 6 months after the intervention:
Knowledge was measured using a questionnaire consisting of 3 sections: how to cross the street (3 questions), how to recognize an emergency and dial 911 (3 questions), and how to avoid strangers (4 questions).
[only data about calling 911 were used in this analysis]
Number of participants:3316 children (51% boys, 49% girls)
Age: 15–17 years
The following outcomes were measured:
regarding their willingness to perform CPR with 5 hypothetical scenarios with cardiac arrest (stranger, trauma, child, elderly and relative); they were asked about their actions after summoning help and possible reasons not to perform full CPR
Knowledge: questionnaire with questions concerning their theoretical knowledge on FA and resuscitation
Attitude: questionnaire about their attitude towards first aid and resuscitation. The following aspects were asked for: their attitude to first aid and CPR, their confidence in performing CPR in a real-life situation, if they would perform ventilation on a member of their family or stranger, how widely CPR should be taught in the community, whether first aid education should be compulsory for drivers or gun licensing, what they felt was associated with first aid, their previous first-aid education, and whether they think family or friends would like to get first aid training.
26 questions in total, not clear how many questions on knowledge/attitude. A combination of open questions, yes/no and categorical questions was used.
Program: Life-supporting first aid training provided by medical students and emergency physicians
Content: 5 important stages: calling an ambulance, CPR, automated external defibrillation, recovery position, minimizing bleeding and burns. First aid interventions were taught in a hands-on, practice-based way using manikins, and simulation to demonstrate scenarios and wounds.
Duration: 1 week
Outcomes were measured before and immediately after the intervention:
Knowledge was evaluated using a cartoon-style questionnaire which depicted emergency-related actions. The children were asked to place three cartoon-like illustrations in the correct sequence. They were also asked to complete the task with their parents as part of their homework.
Content: CPR and AED training using a manikin, training defibrillator and telephone
Duration: no information available
Control: no training program
Outcomes were measured 6 months after the training:
Skills: performance assessed during mock scenario (an adult collapsed in front of the children), using a 10-item checklist. Students scoring insufficiently for a certain component received half a mark for that component
3.2. Conclusions of the best available evidence
Below we describe the results of 4 of the 13 selected topics (including quality assessment of the studies), as an illustration of the process followed. Results on a 5th topic, AED use, were published earlier.40 Appendix 5 shows the findings of all 30 included studies, and Appendix 6 gives an overview of the limitations in study design (Supplementary materials).
3.2.1. Helping behaviour
We found 6 studies measuring helping behaviour, including one randomized controlled trial,12 2 cross sectional studies,33,38 and 3 case series.18,19,27 For overall willingness to help, in children from 11 to 19 years, 27% to 38% is willing to provide basic life support,19,38 31% to 55% is willing to provide chest compressions,27,38 43% is willing to provide mouth-to-mouth ventilations,27 and 32% is willing to use an AED.27 According to one study, willingness to perform CPR did not correlate with theory score or independent skills assessment (raw data were not presented),18 however in two other studies it was shown that training statistically significantly increased willingness to help or to perform CPR.12,38
In two studies self-efficacy or confidence in helping was measured. After training, 54% of children aged 11–12 years thought they would be capable of saving a life18 and the self-efficacy in children of 13–14 years old was significantly higher.12
Factors that negatively influence attitudes and behaviour regarding helping were found to be: fear of failing as a rescuer,38fear of hurting the victim,27,38 fear of disease transmission,18,19,27,38 a dirty casualty (vomit, an unpleasant smell),18,19,27bleeding (in/around the mouth),18,19,27 serious injuries,18,19 dangers to the rescuer,19,27 the victim being a stranger,18,19,27,33,38 or drug user,27 being in a public place,19 fear of being sued.27 Factors that positively influence attitudes and behaviour regarding helping are: the victim being a relative,18,27,33,38 the victim being another child,18,27,38 previous first aid training.38
We can conclude that children from 11 to 19 years are willing to provide help, and first aid training is useful to increase their confidence or self-efficacy. During such training it is important to address factors that could influence the attitude of children to provide help.
Since the majority of the studies (n = 5) was observational, the initial level of evidence was “low”. The level of evidence was further downgraded to “very low”, because 5 studies did not include a control group and did not control for confounding (see Supplementary material, Appendix 6).18,19,27,33,38 In addition, we detected indirectness, since the included studies did not measure actual behaviour, but rather a surrogate for behaviour by using a questionnaire and a hypothetical emergency scenario.
3.2.2. Emergency call
Seven different studies measured knowledge and skills concerning calling the emergency number.10,11,14,20,24,25,29 In the only study with children of 5 and 6 years old, a difference in knowledge and skills concerning calling the emergency number could not be demonstrated when comparing children who received training with children without any training (RR: 1.06, 95% CI [0.86;1.32]).29 In two studies, with children of 6–7 years and 10–12 years old, the knowledge of the emergency number (measured at 5 or 6 months after training) improved significantly after training, for example from 16% to 77% in the children of 6–7 years old.10,14 However, this was not the case in one study with children at the age of 11–12 years.11 The children with the age of 6–7 had significantly improved skills 5 months after training. More in detail, 50% gave correct emergency call information, compared to 6% in children without any training.10 The children of 11 to 12 years old showed significant improvement in calling the emergency number at a satisfactory manner after training, from 35% to 69% 1 week after training.20 A significant improvement in giving the necessary information could not be shown for children between 13 and 16 years who followed CPR training, compared to children who did not receive a training program (RR: 0.94, 95% CI [0.76;1.16]).24 One year after first aid training, the ability to call the emergency number depended on the specific scenario for children between 11 and 16 years.25 Overall, we can conclude that children from 6 to 16 years are capable of calling the emergency number. In Table 2 an overview of all data concerning the emergency number is given.
Table 2Synthesis of findings for emergency call, choking and recovery position.
No. of studies, No. of participants
First aid training (versus no training or before training) to children of
2-point increase in test score forknowledge and skills concerning the emergency number
*Effect measure calculated by the reviewer(s) using Review Manager software.
§Effect measure and confidence interval not available.
Since the majority of studies (n = 6) are experimental studies, the initial level of evidence was “high”. We downgraded this level to “low”, because of limitations in study design (no randomization in 3 studies,11,14,24 unclear lack of allocation concealment in 3 studies,10,25,29 unclear blinding in 2 studies,10,24 and no control group in 1 study20, see Supplementary material, Appendix 6), and because of imprecision (lack of data,10,11,14,20 large variability in results,25 or low number of participants10,11,24,25,29).
In two studies it was shown that in children from 10 to 12 and 11 to 16 years, knowledge about first aid for choking improved significantly after training, for example from 0% to 100% for the 11–16 years old group of children.14,36 In one study a significant increase in skills was also shown for children with the age of 11–16 years, from 0% to 95% of the children immediately after training, and 67% of the children 2 months after training.36 Details on the data from these studies can be found in Table 2.
Since one of the included studies is an experimental study (controlled before after study), the initial level of evidence was “high”. However, this level was downgraded to “low”, because of limitations in study design (no randomization,14 and no control for confounding36, see Supplementary material, Appendix 6) and imprecision (lack of data,14,36 and low number of participants36).
3.2.4. Recovery position
In five studies it was shown that the knowledge concerning the recovery position, and the skills to place a victim in a correct recovery position, improved significantly following training of children of 6–7 and 10 to 12 years old.10,11,15,23,34In children of 11–12 years for example, the skills to perform a correct recovery position improved from 8% to 50%, 5 months after training.34 Detailed data extraction is given in Table 2.
Since the majority of studies are experimental studies, the initial level of evidence was “high”. We downgraded this level to “low”, because of limitations in design (no randomization in 3 studies,11,15,34 unclear allocation concealment in 1 study,10unclear blinding in 3 studies,10,15,34 and no control for confounding in 1 study23, see Supplementary material, Appendix 6) and imprecision (lack of data,10,11,23 or low number of participants10,11,23,34).
3.3. From evidence to an educational pathway
Below, the practice experience of the panel members is described for the selected examples, which, together with the available evidence led to the final educational pathway, containing educational goals for different age groups (see Table 3 for the educational pathway based on all selected topics). In Table 3 it is indicated when a child could be encouraged to learn about certain first aid interventions (indicated as ‘E’), should achieve the educational goals (indicated as ‘K’) and should repeat the content (indicated as ‘R’).