Knowledge, attitude, and determinant factors towards emergency first-aid utilization among public transport service drivers in Injibara, northwest Ethiopia

Abstract

Background

Providing timely first-aid by trained responders can reduce deaths and disabilities from road traffic accidents, a leading global cause of death. Ethiopia ranks 19th worldwide and 4th in Africa. Therefore, this study assesses the knowledge and, attitudes toward emergency first aid, and its factors among public transport drivers in Injibara, Ethiopia.

Objective

To assess the Knowledge, and Attitude towards first-aid utilization and its associated factors among Public Transport Service Drivers in Injibara, Northwest Ethiopia, 2023.

Methods

A cross-sectional study was conducted involving 419 public transport drivers, selected systematically based on vehicle side numbers, starting with a random choice for the first respondent. Subsequent participants were chosen at every second interval (k = 2). A structured questionnaire was used to collect relevant data. Binary logistic regression was performed using SPSS V.26 to assess the associations between independent and dependent variables. The strength of these associations was measured using odds ratios and 95% confidence intervals, with a P-value < 0.05 deemed statistically significant.

Result

The study revealed that the prevalence of good knowledge and favorable attitudes toward first-aid utilization was 33.2% and 38.2%, respectively. Participation in first-aid training (AOR = 0.566, p = 0.027), access to a first-aid kit (AOR = 1.65, p = 0.027), and prior experience using first-aid at accident scenes (AOR = 0.476, p = 0.014) were factors associated with better first-aid utilization. Drivers who had used a first-aid kit (AOR = 0.476, p = 0.014) and those exposed to training (AOR = 0.486, p = 0.034) demonstrated more positive attitudes toward first aid.

Conclusion

The knowledge and attitude toward first-aid utilization remain low. Participation in first-aid training, access to first-aid kits, and experience using them during accidents were factors associated with improved knowledge. Additionally, drivers who have used first-aid kits and received training tend to have a favorable attitude toward their use. Therefore, relevant authorities must enhance the availability of first-aid kits, increase the exposure of drivers, and provide training to drivers to increase their knowledge and favorable attitude towards first-aid utilization.

Clinical trial number

Not applicable.

Introduction

First-aid refers to the immediate assistance provided to an injured person at the scene of an accident until professional help arrives [1, 2]. It is one of the six pillars of pre-hospital care and involves training laypeople to care for accident victims effectively [3]. Globally, road traffic accidents (RTAs) result in 1.35 million deaths annually, particularly in low- and middle-income countries, leading to substantial financial and economic losses for individuals, families, and nations [4, 5]. Timely first aid, which includes stopping life-threatening bleeding, opening airways, and splinting fractures, is crucial for preserving life, reducing suffering, preventing further injury, and encouraging recovery [4, 6, 7].

In Ethiopia, the high rate of RTA-related casualties underscores the importance of first-aid in reducing healthcare costs and fatalities. Educated individuals who provide immediate first-aid can significantly improve survival and reduce the severity of injuries. According to the International Federation of Red Cross societies, bystanders who administer first-aid save millions of lives annually. A study showed that hospitalized individuals with severe injuries who received first aid, such as airway protection, hemorrhage control, and gentle handling, either recovered or showed improvement, indicating the critical need for drivers to be equipped with basic -first-aid knowledge and skills [8, 9].

Despite this, many drivers lack adequate first-aid training and awareness. Only 38.6% of drivers in Ethiopia have used a first aid- kit, and many are unaware of essential techniques such as opening constricted airways [3]. This suggests that improving drivers’ first-aid training could potentially save lives in traffic accidents. The high prevalence of injuries in Ethiopia highlights the need for better first-aid services and collaboration among all stakeholders to prevent and promptly treat injuries [10].

Road traffic accidents lead to loss of life and impose significant financial burdens due to medical expenses and productivity losses. Immediately following an accident, the “golden hour” is crucial for the victim’s survival and recovery. Failure to administer timely first-aid can exacerbate injuries and jeopardize health and survival. In developing countries, first-aid interventions have been shown to reduce mortality rates by 25% [11].

A study conducted at Sharjah, United Arab Emirates (UAE) highlighted that although about 65.7% of drivers can correctly define first-aid, many have not applied it in emergencies, often due to concerns about severe injuries like breathing difficulties and bleeding wounds [12]. The lack of formal first-aid training among drivers is a significant barrier to providing aid. Airway obstruction is a leading cause of death at accident scenes, yet only a small percentage of victims receive proper support. Delays in medical treatment further worsen outcomes, with few victims reaching medical facilities within the critical first hour [3, 10, 13]. Studies indicate a decline in first-aid training among drivers, with a lack of formal training identified as a significant barrier to aiding [14, 15].

The high incidence of road traffic accidents, especially on interstate highways in the Amhara Region, emphasizes the need to prioritize first-aid training as a significant public health concern. The Amhara Regional Bureau’s 2023 annual report highlights the severity of the situation, with 1,539 accidents resulting in 67 fatalities. In the Awi zone alone, 72 accidents led to 101 deaths and 43 severe injuries, with no reported driver support at the scenes. These statistics underscore the urgent need to assess and improve drivers’ knowledge and attitudes toward first-aid to mitigate the impact of road traffic accidents [3, 16,17,18].

The study aims to investigate the knowledge and attitudes regarding first-aid among public transport drivers in Injibara, an area where this topic has not been thoroughly explored. By examining these aspects, the study seeks to enhance road safety and improve outcomes for accident victims.

Methods and materials

Study area and period

The study was conducted at the Injibara public transport terminal from January to March 2023. Injibara, located in northwest Ethiopia, is the administrative center of the Awi zone. The town sits at an elevation of 2560 m and experiences heavy rainfall, supporting multiple crop harvests annually. With a population of 21,065, Injibara public transport system includes 826 vehicles, serving over 5,000 passengers daily across about 200 routes [19].

Study design

A cross-sectional study design was conducted.

Source population

All public transport drivers in Awi Zone.

Study population

Public transport drivers operating at the Injibara terminal during the data collection period.

Inclusion and exclusion criteria

Inclusion Criteria: Public transport drivers serving routes from the Injibara terminal.

Exclusion Criteria: Public transport drivers serving routes from the Injibara terminal and have no side number registration.

Sample size determination

The sample size was calculated using the single population proportion formula.

A study on taxi drivers in Addis Ababa, Ethiopia showed that the magnitude of first-aid knowledge was 46% [3].

$$\:\frac{{\left(za/2\right)}^{2}*p\left)\right(1-p)}{{\left(d\right)}^{2}}=\frac{{\left(1.96\right)}^{2}*0.46\left)\right(1-0.46)}{{\left(0.05\right)}^{2}}=381$$

Where:

n = required sample size = 381.

p = proportion of first-aid knowledge of taxi drivers at Addis Ababa (0.46).

d = margin of sampling error = 5%.

Z = the standard normal confidence internal = 1.96 the calculated sample size is 381.

When a 10% non-respondent rate was added to the final sample, the size was 419.

Sampling technique

A systematic random sampling method was used to select drivers for the study. The Awi Zone Transport Department provided information on the 826 public transport services operating from the Injibara terminal. To ensure a representative sample, participants were chosen systematically. Drivers meeting the inclusion criteria were first identified and then listed based on side numbers. The first respondent was selected randomly, and subsequent respondents were chosen every kth position, where k was calculated as the ratio of the population (N) to the sample size (n), resulting in k = N/n = 826/419 ≈ 2.

Study variables

Dependent variables

Knowledge of emergency first-aid, Attitude towards emergency first-aid.

Independent Variable

Socio-demographic factors: Age, sex, marital status, educational status, religion; Training-related factors: First-aid training, types of first-aid training, certification obtained; First-aid kit-related factors: Availability of first-aid kit, usage of kit, completeness of first-aid kit; other factors: Driving experience, origin of license, public transport level.

Data collection procedures

Data collection was conducted using a pre-tested structured questionnaire and an observational checklist (Annex 1) through face-to-face interviews. The data collection tool has five categories: sociodemographic characteristics with eight items, first-aid knowledge assessment questionnaire with ten multiple-choice items, first-aid attitude assessment questionnaire with nine five-level Likert scale items, first-aid training-related questionnaire (five items), and first-aid kit related questionnaire and checklist (five items). These tools were developed from the literature and guidelines [3], were initially prepared in English, then translated into Amharic, and back-translated to ensure consistency. The data collection team consisted of two clinical nurses, one public health supervisor, and one facilitator from the Zonal Transport Department. The principal investigator provided a two-day training session covering the study objectives, tool usage, interviewing techniques, and data reporting. Data collection was scheduled to align with the drivers’ routines, beginning before their departure at 5:30 p.m. and continuing after their return from 2:00 p.m. onwards. Facilitators from the Zonal Transport Department supported the process, with data collectors stationed at the terminals based on the sample from scheduled public transport lines.

Operational definitions

First-aid knowledge

Each knowledge assessment question awards one point for a correct single response. Then, the scores were summed up and the mean score was calculated. Those who scored above or equal to the mean were considered to have good knowledge.

First-aid attitude

Drivers’ attitudes were measured using a nine-item five-point Likert scale, with responses indicating very low and low attitudes receiving scores of 1 and 2, while 3, 4, and 5 indicate neutral, high, and very high attitudes, respectively. The scores were summed up and the mean attitude score was calculated. Finally, those who scored greater or equal to the mean were considered to have positive attitudes.

Completeness of first-aid kit

The completeness of a first-aid kit was categorized based on the presence of main first-aid items, with kits considered complete if they contain more than 75% of the essential items, and incomplete if less than 75%. The mandatory items in the first aid kit, as outlined by the Federal Transport Authority, include scissors, sterile gauze pads or wound dressings, gentian violet or Savion, alcohol, medical tape or wound plaster, cotton, a surgical blade, a small towel, disposable gloves, and a small round basin or kidney dish [3].

Data quality management

Training sessions were held for data collectors, supervisors, and facilitators to familiarize them with the tools, field methods, inclusion and exclusion criteria, and record-keeping practices. The researcher and supervisor closely monitored the interview process, conducting spot checks and reviewing completed questionnaires daily to ensure completeness and consistency. A pre-test was conducted with 5% of non-selected respondents in Font Selma town to identify and address potential issues. Based on the feedback, adjustments were made to the questionnaire to improve clarity and eliminate bias before full implementation. In addition, the pilot test result of the data collection tool shows acceptable reliability with a Cronbach’s α value of 8.1.

Data analysis procedures

The completed questionnaires were entered into EpiData 4.6 and then exported to SPSS version 26 for data cleaning and analysis. Descriptive statistics, including frequency measures, were presented in tables. To identify associations between variables, individual independent variables were fitted into a binary logistic regression model. Variables with a p-value ≤ 0.2 were included in a multivariable logistic regression model to account for potential confounders. The Hosmer-Lemeshow test assessed the model fitness, and associations were evaluated using odds ratios and 95% confidence intervals, with statistical significance set at p < 0.05.

Result

Socio-demographic characteristics of the study participants

A total of 419 male drivers were included, achieving a 100% response rate. Of the respondents, 223 (53.2%) were in the age range of 18–31 years. The mean age was 32.4 years, with a standard deviation (SD) of ± 7.153. In terms of educational background, 314 (74.9%) had completed secondary education or higher, while 105 (25.1%) had less than secondary education. Regarding marital status, 274 (65.4%) were single, and 145 (34.6%) were married. As for licenses, 274 (65.4%) were issued in the Amhara region, while 145 (34.6%) were from other regions. Regarding bus level, 235 (56%) were level one, and 52 (12.4%) were level three (Table 1).

Table 1 Socio-demographic and other characteristics of public transport drivers (n = 419), Injibara, 2023

Knowledge of public transport drivers towards first aid

Among the 419 participants, only 139 (33.2%) had good knowledge of providing first-aid during road traffic accidents (RTAs), while 280 (66.8%) had poor knowledge. Just 51 (12.2%) believed first-aid should be administered promptly during RTAs, and only 42 (10%) recognized public transport drivers as potential first-aid providers. Only 14 (3.3%) correctly identified breathing maintenance as a priority in first aid, and while 62 (14.8%) recognized breathing issues as airway problems, 76.1% were unaware of how to provide breaths to victims.

Regarding patient positioning after trauma, 326 (77.8%) did not know the correct position, with just 20 (4.8%) placing victims sideways and 38 (9.1%) positioning them face up. Additionally, only 28 (6.7%) applied tourniquets for severe bleeding, and 72.8% were unaware of how to stop bleeding. For fractures, 42 (10%) mentioned using splints, while 103 (24.6%) were unsure how to manage them (Table 2).

Table 2 Knowledge of public transport drivers towards first aid (n = 419), Injibara, 2023

The attitude of public transport drivers toward first aid

Eighty-six participants, accounting for 20.5% of the total respondents, recognized the importance of providing immediate first-aid to road traffic accident (RTA) victims at the scene. In addition, 79 individuals (18.85%) expressed their willingness to administer first-aid to RTA victims.

The reasons for unwillingness to provide first-aid varied: 15.3% cited a fear of blood, 16.0% fear of infection, 18.4% concerns about medico-legal implications, and 26% reported not knowing what to do (Table 3).

Table 3 Attitude of public transport drivers towards first-aid (n = 419), Injibara, 2023

Factors associated with first-aid knowledge

In the multivariable logistic regression analysis, participation in first-aid training, and availability of a first-aid kit, and ever-use kit were found to be significantly associated with first-aid knowledge.

This study revealed that those drivers who were not exposed to training regarding first-aid were 43.4% times less likely to know first-aid utilization than outer parts [AOR = 0.566 (0.342–0.938), p = 0.027). Availability of the kit was 1.65 times increased the knowledge towards first aid utilization than outer parts [AOR = 1.65(1.058–2.572), p = 0.027]. On the other hand, drivers who did not ever use a first-aid kit were 52.4% times less likely to have good knowledge of first-aid utilization [AOR = 0.476(0.263–0.860), p = 0.014) (Table 4).

Table 4 Factors associated with knowledge towards first aid among drivers (n = 419), Injbara, 2023

Factors associated with attitude towards first aid

In the multivariable logistic regression, public transport drivers with exposure to first-aid training and those who had used a first-aid kit demonstrated more positive attitudes toward first aid.

This study revealed that those drivers who had not had the experience of training regarding first-aid were 51.4% times less likely to have a positive attitude towards first-aid utilization than outer parts [AOR = 0.486(0.249–0.947), p = 0.034). On the other hand, drivers who had not ever used a first-aid kit were 52.9% times less likely to have a positive attitude towards first-aid utilization [AOR = 0.471(0.266–0.836)), p = 0.010 (Table 5).

Table 5 Factors associated with attitude towards first aid among drivers (n = 419), Injbara, 2023

Discussion

The study’s findings highlighted the level of knowledge and attitude towards first-aid utilization and its associated factors among drivers in Injibara, northwest Ethiopia. This study revealed that 74.7% of respondents had not undergone prior first-aid training, and 85.2% of public transport drivers had no access to, nor had ever utilized, a first-aid kit a figure closely resembling results from a study involving taxi drivers in Addis Ababa [10, 20]. This parallelism underscores a potential lack of focus on providing first-aid training to public transport drivers by both the Federal Transportation Authority and public transport associations. Furthermore, a substantial percentage (96.3%) of drivers demonstrated awareness of the definition of first aid, surpassing the figures from similar studies conducted in India and Addis Ababa [16, 21].

The findings regarding the adequacy of first-aid knowledge among public transport drivers in Injibara, where only 33.2% demonstrated sufficient understanding, reveal a concerning gap in key first-aid concepts. The study highlighted that most respondents lacked knowledge of the correct definition of first aid, its components, the proper timing for administering it, and the appropriate management of critical situations, such as stopping bleeding and positioning during fractures. This result is in line with studies from Sharjah, where 34%, and Nigeria, where 37.6% of drivers had sufficient knowledge [12, 22]. In addition, this finding aligns with a study conducted in Addis Ababa among taxi drivers, which similarly reported significant gaps in first-aid knowledge [3].

The similarity in findings between these studies suggests a common issue of inadequate first-aid knowledge among public transport drivers in different regions of Ethiopia. In contrast, studies conducted in the United Arab Emirates, Cameroon, and Uganda reported that 45.8%, 65.7%, and 86.7% of respondents, respectively, were knowledgeable about first aid [13, 23, 24]. This indicates a significant disparity in first-aid knowledge levels between the drivers in Injibara and those in the United Arab Emirates, Cameroon, and Uganda. The higher levels of first-aid knowledge among drivers in the United Arab Emirates, Cameroon, and Uganda can be attributed to several factors, including differences in training programs, better access to resources, and cultural attitudes that emphasize the importance of first-aid education. These countries may have more comprehensive training systems for public transport drivers and prioritize health and safety practices more effectively, resulting in enhanced preparedness for emergencies [25].

The findings from the study reveal a concerning lack of positive attitudes toward first-aid among respondents, with only 38.2% showing a favorable attitude. It is particularly troubling that the majority of public transport drivers expressed an unwillingness to provide first-aid at the scene of an accident. Additionally, many respondents believed that knowledge of first-aid was unnecessary and should not be included in the driving curriculum. These results are consistent with a similar study conducted in the United Arab Emirates, where 70% of respondents also demonstrated a negative attitude toward first aid. This highlights a widespread issue regarding the perception and importance of first-aid skills among the public [13].

The study also shed light on disparities in the availability of first-aid kits among public transport drivers, with only 49% of respondents meeting the recommended criteria. This discrepancy suggests a potential lack of adherence to regulations set forth by the Federal Transport Authority and underscores the need for stricter enforcement mechanisms to enhance road safety. The study found that demographic factors such as age, marital status, educational background, public transport level, and driving experience did not show a significant association with first-aid knowledge and attitudes. This contrasts with a study done for road traffic accident injuries in Africa [10].

However, participation in first-aid training and access to a first-aid kit were identified as significant factors. Public transport drivers who had access to a first-aid kit were 1.65 times more likely to have good knowledge of first-aid utilization while drivers not ever utilized a first-aid kit were 52.4% times less likely to know about the utilization of first-aid. This finding aligns with a study in Addis Ababa [3].

Furthermore, public transport drivers who had undergone first-aid training and had experience using a first-aid kit demonstrated significantly more positive attitudes toward first aid. This finding underscores the critical role that both training and access to essential resources play in shaping drivers’ knowledge, skills, and attitudes regarding the provision of first aid in emergencies. By equipping drivers with the necessary training and resources, we can enhance their confidence and willingness to respond effectively when faced with accidents, ultimately contributing to improved road safety and better outcomes for injured individuals.

Limitation of the study

Since this study is cross-sectional, it does not demonstrate a cause-and-effect relationship. Additionally, we cannot include the practice aspect due to the challenges associated with measuring practices, which primarily occur at the time of the accident.

Conclusion

This study revealed that the knowledge and attitude towards first-aid utilization among public transport drivers in the Injibara car terminal were 33.2% and 38.2% respectively which is low.

Exposure to training towards first aid, availability of first-aid kits, and ever use the first-aid kits were factors associated with knowledge towards first-aid utilization. Exposure to training and availability of first-aid training were positively associated while not-ever-used first-aid kits were negatively associated with knowledge of first-aid utilization. On the other hand, exposure to training and ever use of first-aid were factors associated with favorable attitudes towards the utilization of first-aid.

To increase drivers’ knowledge and attitudes regarding the use of first aid in emergencies, it is recommended to provide training on first aid and to increase practical experience. Additionally, ensuring that first aid kits are available in vehicles is essential to increase knowledge. Therefore, regional and federal road authorities should prioritize the implementation of these factors that influence attitudes and knowledge about first aid utilization.