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Using accident injury data to assess the impact of community first aid training
Publ. Hlth, Lond. (1985) 99, 98-109
Using Accident Injury Data to Assess the Impact of Community First Aid Training A. lan Glendon
Appfied Psychology Division, Management Centre, The University of Aston in Birmingham, Gosta Green, Birmingham, B4 7ET Stephen P. McKenna
MRC/ESRC Social and Applied Psychology Unit, Department of Psychology, The University, Sheffield $10 2TN
In a U.K. First Aid Community Training Project from a town with a population of around 19,000 over 1200 people took a 4-h emergency first aid course. Independent evidence for the effects of the training was obtained from hospital casualty registers and from police road traffic accident data. The data indicated that the first aid training significantly reduced the accident injury rate in the community. Age, sex and accident location effects are discussed with reference to the disaggregated empirical data. It is argued that there are substantial indirect effects from the training, particularly the influence of first aid-trained adults upon children, as well as direct effects upon trained individuals shown by earlier studies. Introduction The treatment benefits of first aid training are well known and accepted. Modern first aid was " i n v e n t e d " about a century ago to help the victims of accidents and sudden illness when qualified medical aid was not available. Training is designed to equip people with the skills necessary to maintain life, reduce suffering, prevent the condition worsening and to help promote recovery. However, as long ago as 1938 it was thought that as well as being an emergency measure, first aid training was a means of accident prevention? Systematic study of the hypothesis that first aid is a means of accident prevention began in Canada in 1969 and in the U.K. in 1973. The work concentrated upon evaluating changes in accident injury rates following first aid training. F r o m this research, particularly in the U.K., much has been learnt of the process linking first aid training, safer behaviour and reductions in accident rates. Canadian research indicated that first aid training was associated with safer driving behaviour 2 and with a reduction in road traffic accident rates? To overcome problems associated with the use of retrospective and cross-section data, prospective studies of workers who attended 4-h courses in emergency first aid training at two factories were carried out. 4, 5 The course, in which technical terms and jargon were eschewed, concentrated upon essential life-saving treatments, and explanations were kept as simple as possible. As much practical work as possible was included, and trainees were required to demonstrate their ability to carry out life-saving techniques effectively. The results showed that, contrary to expectation, in the period prior to training the group which volunteered for training had a worse accident injury frequency rate than a matched control group. Evidence from subject interviews before and after training suggested that 0033-3506/85/020098-F 12 $02.00/0
~ 1985 The Society of Community Medicine
Impact of Community First Aid Training
99
this finding was not the result of differences in willingness to report injuries. It is possible to speculate that people who have more experience of accidents may perceive a greater need for learning how to treat the injuries which result from them. In the post-training period, when compared with the baseline of accident injury frequency in the control group, there was a statistically significant reduction in the reported accident injury frequency of the first aid-trained group. 4,5 It has been suggested that first aid training increases motivation to avoid injury), 7 Following the factory studies, further questions seemed worthy of study. First, "is it possible to generalize factory-based findings to other settings?" Second, " i f so, is it possible to assess the effectiveness of the training in a whole community where data are less easy both to collect and to interpret?" Third, "are the motivational benefits of first aid training confined to those trained, or do trainees also influence others' environment or possibly their behaviour?" A major reason for selecting a community for study was to test the hypothesis that there would be indirect effects of the training upon accident injury rates of those who had not themselves received first aid training. The methodological difficulties of researching a community need to be weighed against extending the benefits of first aid training demonstrated in the factory studies to a whole community, where there is much greater scope for accident injury reduction. In an attempt to answer these and other questions, a community study was carried out in Leek, Staffordshire. Among other reasons, this town was selected because of its relative isolation from other urban centres, its range of industries and the limited employment migration to and from the town. These selection factors meant that data sources could be directly linked to the population receiving training. However, it was not possible to record the names of injured individuals directly because of the confidentiality of medical records, and hence it was not possible to specify the accident performance of trainees. The combination of the matched control (the factory studies) with field studies which incorporate a quasi-experimental design allows for a balanced approach which can strengthen findings from any single method. Method
A total of 120 courses were run in Leek over a 27-month period and 1204 people took either all or part of the course. The standard 4-h course was taught by a small team of specially trained, experienced St John Ambulance instructors. The course was the same as that developed during the factory studies and is described elsewhere), 5 Seventy per cent of the trainees lived in Leek itself and most of the remainder came from nearby villages. Attitudinal and other effects of the first aid training were measured through postal surveys conducted before and after the first aid training programme. Accident injury data were collected from hospital casualty registers and from police road traffic accident (RTA) records. The North Staffordshire Royal Infirmary (NSRI) is 13 miles from Leek and has a 24-h accident and emergency service. The total catchment area of the NSRI has a population of approximately 650,000 people. From the NSRI, data were collected on monthly totals of numbers of accident injuries treated, and for Leek residents additional information on the injured individual and location of accident was also collected. Police RTA records enabled a comparison to be made between inj ury accidents occurring in the Leek area and those occurring in the rest of Staffordshire (from the beginning of 1974 - the date of the most recent county boundary changes). Three categories of RTA data are used by police in the U . K . - fatal accidents, other-injury accidents and damage-only
100
A. I. Glendon and S. P. McKenna
TABLE1. A comparison of accident injuries treated at the North Staffordshire Royal Infirmary (NSR1) sustained by Leek residents and all others in the hospital catchment area over two equal periods of time No. of accident injuries 26-Month periods
Leek
Rest of NSRI catchment area
Prior to first aid training in Leek Post first aid training in Leek Percentage change
1861
122,896
1671
128,659
- 10.2%
+ 4.7 ~,
y~ = 10.25, d.f. = 1, P < 0.01. Source: NSRI Casualty Register 1974-1979.
accidents. Damage-only accidents were excluded from this study mainly because these would be subject to the greatest amount of under-reporting and therefore be the least accurate of the three categories. T o o few fatal accidents occur to reveal significant changes over the relatively short time periods available. Therefore, the numbers of fatal accidents and other-injury accidents were aggregated to form the basis for R T A comparisons.
Results (1) Table 1 compares the numbers of accident injuries sustained by Leek residents with those from the rest of the North Staffordshire Royal Infirmary (NSRI) catchment area who were treated at the N S R I during two periods of 26 months - the first prior to the first aid training in Leek and the second during and after completion of the training exercise. Both periods, which were not contiguous, began on 1 January. These are the longest comparison periods available since the most recent county boundary changes. It can be seen that the number of accident injuries to Leek residents treated was 10-2% lower in the second period, while the number of accident injury treatments to people from the rest of the N S R I catchment area was 4-7% higher. This difference was statistically significant (P < 0.01). Table 2 shows the number of road traffic injury accidents occurring in the Leek area and in the rest of Staffordshire during the same two 26-month periods as were used for the N S R I data. It can be seen that the number of injury RTAs occurring in the Leek area was 3- 5 % higher in the second period, while the number of injury RTAs in the rest of Staffordshire was 14.8% higher, which is statistically significant (P < 0.05, one-tailed). A one-tailed test is justified on the grounds that previous research had shown that first aid training is associated with an improved injury R T A record), "~
Discussion (1) The highly significant findings shown in Table l indicate a marked reduction in the number of Leek residents seeking emergency treatment for accidents at the N S R I during the period following the community first aid training. The R T A data show that between the same two time periods the increase in the fatal and other road traffic injury accident
Impact of Community First Aid Training
101
TABLE2. A comparison of road traffic accidents involving injury in Leek and the rest of Staffordshire over two equal periods of time No. of injury road traffic accidents 26-Month periods Prior to first aid training in Leek Post first aid training in Leek Percentage change
Leek
Rest of Staffordshire
678
9068
702
10,413
+ 3-5~
+ 14,8~o
X2 = 3.35, d.f. = 1, P < 0.05 (one-tailed). Source: Staffordshirepolice and Leek police road traffic accident data 1974-1979. rate for the Leek area was less marked than that for the control area. The results obtained from these independent sets of data require examination in order to determine what factor or factors might be operating. Before reviewing out hypotheses in the light of the results obtained, it is first necessary to consider factors which might be expected to provide possible explanations (other than the first aid training) for the findings. Our first task is to attempt to account for the statistically significant improvement in accident injuries to Leek residents reported to the NSRI. The following explanations for the N S R | result may be postulated. (1) There was a sudden relative decrease in the Leek population during the study. This was disproved by a search of the relevant Office of Population Censuses and Surveys Monitors, which revealed that the populations of both areas remained fairly stable. 1° (2) People trained in first aid were not having fewer accident injuries, but were simply treating themselves and others who were injured, thus avoiding the need for hospital treatment. The N S R I receives mainly seriously injured casualties and thus, even if such casualties had received first aid, they would still require further medical treatment. The first aid courses stressed the need to seek qualified medical aid promptly for potentially serious injuries. It has been found that following first aid training, workers claimed that they were more willing to report injuries?, 7 I f valid for the community, this finding would lead to an increase in the number of accident injuries reported. (3) There was some special factor operating in Leek which made it a " s a f e r " place and that this happened to coincide with the first aid training. In all our close connections with the town before, during and after the research period, we never encountered any other factor that could conceivably account for the observed accident injury reductions. Contact extended to interviews with nearly all local general practitioners and hospital staff, district community physicians, police road traffic safety staff, members of St John Ambulance, local newspaper staff and other citizens. (4) There was a publicity effect of the research project upon the community which influenced the observed accident injury rates. There was publicity about the project in the local press, on local radio, in the regional press, through posters and at the Leek Annual Show. But, as in the courses themselves, this publicity made no reference to safety or to accident reduction and was directed towards recruiting trainees.
102
A. L Glendon and S. P. McKenna
(5) Our own large-scale postal surveys affected accident rates within the town. Questionnaires were distributed to half of the households in Leek prior to the training and to a larger number after the training. Hospital data collected subsequent to the second comparison period do not support a hypothesis of a systematic biasing effect from the questionnaire surveys. (6) The total number of accident injuries did not decrease, but these became less serious, perhaps because some at least were treated more promptly than before or because less serious injuries were more accurately diagnosed. This suggests that a reduction in accident injuries to Leek residents reported to the N S R I might correspond to an increase in those reported to the local Cottage Hospital, which treats minor injuries between 0800 and 2000 h. However, data from the Cottage Hospital (not reported here) do not support this hypothesis because there was no significant difference between injury treatments to Leek residents and to non-Leek residents between the same two time periods. The research principle of data triangulation upholds the importance of seeking evidence from more than one source to test a hypothesis, 11 and we therefore turn next to consider the quality of the evidence provided by the R T A data. There are a number of problems associated with using R T A data as a measure of changes in the road user behaviour in this and other studies.* In order to have confidence in the R T A data, certain assumptions have to be made, in particular that any errors occurring would be random and constant over time between Leek and the comparison area. While these are major assumptions and mean that the R T A data are not conclusive in themselves, the fact that the trends observed are similar to those found for the N S R I accident injury data means that the R T A data do provide supportive evidence for the N S R I findings. Having discussed all likely alternative explanations for the observed improvement in accident injury rates, we have confirmed the hypothesis implied in our first question, that it is possible to show reductions in accident injury rates resulting from first aid training within a community as well as within a factory. Evidence that first aid training influenced the accident injury rate in Leek at the time of the study is very strong. However, a problem remains which cannot be explained by the data presented. This concerns the size of the effect from the first aid training upon recorded accident injury rates. Even allowing for the possibility that volunteers for the community training had a worse pretraining accident injury rate than did non-volunteers, 1°, 5 considering that approximately 6 ~ of Leek citizens were trained in first aid, the size of the reduction (over 10~o ) in accident injury rate is much larger than could be expected solely from improvements among those trained. Previous studies ~,5 found reductions in injury accident rates of up to 30-40~o among those trained in first aid, but even if it is assumed that similar reductions for trainees occurred in this community, there is still a large residual reduction to be accounted for. F r o m the data in Table 1, it may be calculated on the basis of expected numbers of accident injuries that there were 377 fewer of these in Leek than would have been expected in the post-training period. I f the most optimistic figure from previous studies of a 4 0 ~ reduction in accident injuries to trainees as a direct result of first aid training is assumed, this only reduces the total by 47 accident injuries (1200/19,000 x 1861 x 40 ~o ), leaving 330 to be accounted for. * General problems in the use of RTA data include : inaccuracies in recording,~2under-reporting by up to 40 for some types of accident,TM 14 and errors in police reporting.15 In this study, police RTA data did not specify numbers of people injured in an accident, there was no control over extraneous factors such as holiday bottlenecks or increases in traffic volume, RTA records included accidents to road users who were not Leek residents and the smallest unit avilable for analysis included rural areas surrounding Leek.
Impact of Community First Aid Training
103
This leads to the conclusion that this figure must be due either to trainees affecting the environment or the behaviour of others or to some other factor or factors. The possibility that factors other than the first aid training might have been operating in Leek at the time of the study has already been dismissed. Therefore, this leaves the hypothesis that those trained in the community significantly influenced the environment or the behaviour of others, and that it is this indirect effect of the training which accounts for the residual improvement in the accident injury reduction. In order to test this hypothesis, we turn first to evidence on some of the characteristics of those who received training in the community. F r o m our survey data, a number of differences in the characteristics of volunteers and non-volunteers emerged, s Compared with non-volunteers, volunteers for first aid training were statistically significantly more likely to be: (a) between 21 and 40 years of age; (b) female; (c) in employment; (d) in contact with others in the 15 years and under age group, both at home (as a parent) and at school. We also know that about 2 0 ~ of those trained were between 6 and 15 years of age. The surveys indicated that around half of those trained - both young and old - reported passing on important first aid knowledge to others, particularly to family members and to workmates or friends, s, 17 Because only 6~o of Leek residents were trained in first aid during the study, we would not expect to find direct effects of the training upon accident injury rates to be very marked for these particular groups. However, we would predict that marked decreases in accident injury rates as an indirect result (trainees affecting the environment or behaviour of others) would be found for those aged 15 years and under and for those aged between 21 and 40 years. In respect of injury accident location we would predict that decreases in accident injury rates as a result of trainees affecting the environment or behaviour of others would be most marked for those accidents occurring: (a) at school; (b) at home; and (c) at work. In order to test the above predictions, it is necessary to return to the N S R I data in disaggregated form. This is done in the following section.
Results (2) In Tables 3-6, missing data are not shown and have been excluded from all analyses. This accounts for the varying column totals in the different tables. Table 3 shows the differences between the two periods of time in numbers of accident injuries sustained by Leek residents of different age groups which were reported to the NSRI. It will be seen from Table 3 that there are statistically significant differences in accident injuries between pre-training and post-training periods for the 5 and under age group (P < 0-001) as well as for the 6-15 (P < 0.001) and 21-40 (P < 0.005) years of age groups. The corresponding differences for the remaining age groups are not statistically significant. A further breakdown of these data to show sex of injured person is shown in Table 4. The data in Table 4 show statistically significant differences in reported accident injuries for both males (P < 0.01) and females (P < 0.05) in the 5 and under age group, but for males only in the 6-15 (P < 0.01) and in the 21-40 (P < 0.05) years of age groups. The data for sex of injured person, including cases where age was not recorded, are not shown, but statistical analysis indicates no significant difference directly associated with sex of injured person. D a t a on location of the accident which resulted in injury for the same two time periods are shown in Table 5. F r o m the data in Table 5 it will be seen that there are statistically significant differences in reported injuries between the two time periods for home accidents (P < 0.001), for work
104
A. I. Glendon and S. P. M c K e n n a
TABLE3. Differencesin number of accident injuries reported to the North Staffordshire Royal Infirmary during two 26-month periods, by age group No. of accident injuries Age group (years) 5 (~15 16 20 2140 > 40 Totals
Pre-training period 153 405 217 514 550 1839
Post-training period
Expectednumbers post-training
94 317 224 449 566 1650
123-5 361 220-5 481.5 558
y2 value
P
14.09 10.73 0.11 4.39 0.23
< 0.001 < 0.001 N.s. < 0.005 N.s.
accidents (P < 0-01) and for accidents at school (P < 0-001), where fewer were reported in all cases. There is also a statistically significant difference in reported leisure accident injuries (P < 0-001), where more accidents occurred in the second time period. It is possible to obtain more detailed information by cross-tabulating accident location with age group. This breakdown is shown in Table 6. Some of the age categories have been combined in order that statical analyses may be performed. The data in Table 6 show that in the home location there are statistically significantly fewer reported accident injuries to those in the two youngest age groups (P < 0'01 and P < 0-001) in the second time period. For the work location, there is a lower incidence of accident injuries (P < 0.01) reported by those in the 21-40 years of age group following the first aid training. A significantly higher incidence of reported leisure accident injuries is found for all but the two youngest age groups. There are also statistically significant changes in reported accident injuries in the street, with those aged over 40 years reporting more (P < 0.05), and in all types of RTAs, where those aged 16-20 years report more accident injuries (P < 0-05).
Discussion (2) The statistically significant results obtained from the data disaggregated by age groups provide strong support for the hypotheses concerning the distribution of the accident injuries among the various age groups. The age groups 5 years and under, 6-15 years and 21-40 years all showed statistically significant reductions in reported accident injuries between the two time periods. Further disaggregation of these data by sex of injured person shows similar patterns for both males and females in the two youngest age groups, although only the reduction for males is statistically significant for the 6-15 years of age group. However, the 18.8% reduction for females in this age group does not fall far short of the 23-2% reduction for males in the 6-15 age group. As the youngest person to take a community first aid course was aged seven years, any changes in the number of accident injuries to those younger than this can only be attributed to the influence of others. As 262 (22%) of those taking a course were aged between 7 and 15 years, it is possible that some of the improvement in accident injury rates for this age group would be attributable to the direct influence of the training, but that a larger effect would be from parents, teachers and perhaps peers. It seems most likely that there is a marked indirect effect whereby first aid-trained parents influence the environment and
Impact of Community First Aid Training
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A. I. Glendon and S. P. M c K e n n a
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TABLE 5. Accident location of injuries to Leek residents reported to the NSRI in two periods of time Accident injuries in pre-trainlng period
Accident injuries in post-training period
Home Work Leisure School Street R T A - all types
582 310 254 85 151 125
438 244 391 46 158 137
Totals
1507
1414
Location of accident
Expected numbers post-training 510 277 322.5 65-5 154.5 131
y~ value 20-33 7.86 29.10 11-61 0.16 0.55
P < < < <
0-001 0.01 0.001 0-00t N.s. N.s.
TABLE 6. Cross-tabulations of age group with location of accident resulting in injury reported by Leek residents to the NSRI in two periods of time
Location
Age group (years)
Accident injuries in pre-training period
Accident injuries in post-training period
Expected numbers post-training
X2 value
P
Home
~< 5 6-15 16-20 21~40 > 40 Totals
97 105 34 98 248 582
60 46 25 87 220 438
78.5 75.5 29.5 92.5 234
8.72 23.05 1.37 0.65 1.68
< 0.01 < 0.001 N.s. r~.s. y.s.
Work
16-20 21~40 > 40 Totals ~< 5 6-15 16-20 21M0 > 40 Totals
50 162 98 310 11 115 37 69 22 254
40 115 89 244 17 140 63 99 72 391
45 138.5 93.5
1.11. 7.97 0.43
N.s. < 0.01 r~.s.
14 127.5 50 84 47
1.29 2.45 6.76 5-36 26.60
N.s. N.s. < 0.01 < 0-05 < 0.001
< 20 ~< 15 16-20 21~40 > 40 Totals
85 51 25 31 44 151
46 47 15 31 65 158
65.5 49 20 31 54'5
11.61 0-16 2.50 0"00 4-05
< 0.001 N.s. N.S. N.S. < 0"05
~< 15 16-20 21M0 > 40 Totals
22 33 40 30 125
14 51 38 34 137
18 42 39 32
2-29 3.86 0.05 0.25
N.s. < 0,05 N.s. y.s.
Leisure
School Street
RTA-all types
Impact of Community First Aid Training
107
behaviour of their children so that they have fewer accident injuries. It is also likely that there is a similar effect from teachers and others in the school environment. The other statistically significant finding which accorded with the hypothesized effect was that males in the 21-40 years of age group had fewer accidents in the post-training period, while this was not true for females in the same age group. Even if there is a small direct effect of training for this group, the larger part of the decrease must be explained by indirect effects, that is, of first aid-trained adults influencing the environment and behaviour of males in this age group. The finding that females did not show a greater accident injury rate red uction than males between the two periods, given the other findings from the disaggregated data, is not surprising, for it does seem that any direct effects would be diffused among all those who received training, while indirect effects tend to be concentrated upon particular age groups and in particular environments. Further evidence for the existence of indirect effects emerges from the considerable variation between injuries disaggregated on the basis of accident location. The statistically significant results obtained from the data shown in Table 5 enable us to accept the hypotheses on changes in accident injury rates for different locations between the two time periods. Thus the three accident locations showing statistically significant decreases in accident injuries are those predicted, namely: school, home and work. The effects of the school and home environments appear to be much larger, reinforcing the notion of the importance of indirect effects by trained people upon others in these environments. The reduction in workplace accident injuries is too large to be accounted for by direct effects of the training upon trainees, and it thus seems likely that there is also an indirect effect through trained work people influencing either the work environment or the behaviour of their colleagues and workmates. Changes in total numbers of street accident injuries and RTA injuries reported during the two time periods were not statistically significant. For leisure activities, where opportunities to influence either the environment or behaviour of others by personal intervention are less, a reverse effect is found with no significant difference for those aged 15 years and under, but statistically significant increases in reported accident injuries for those in the groups aged 16 years and over. It is likely that opportunities for influencing either the environment or the behaviour of others in either the road, street or leisure environments are likely to be less numerous and more transient than in the home, school and work environments, where personal, familial and social ties are likely to be much stronger factors. The findings on accident location are therefore consistent with the hypothesized indirect effects, and suggest that these are likely to be due to making places " s a f e r " rather than by making behaviour "safer". The findings from the work environment confirm that, while fewer accident injuries are reported for all three working age groups during the second period, it is only for the 21-40 years of age group that the change is statistically significant. The major influence hypothesized is indirect effects of first aid-trained workers upon the work environment of their colleagues, and that the effect is only strong enough to influence the peer group with respect to age. For the other working age groups, any indirect effects may be swamped by other factors. 18,19 In the case of street injuries the over-40 years of age group was the only one to experience more, while for RTA injuries the 16-20 years of age group had significantly morel In the light of the indirect effect hypothesis, it is instructive to observe that people from these two age groups were both less likely to volunteer for the first aid training and less likely to be subject to the influence of others who had been trained.
108
A. I. Glendon and S. P. McKenna
Conclusions The study described provides strong independent support for the carefully controlled studies carried out in factory environments. It has also been demonstrated that by extending the scope of such research beyond the strict experimental setting a greater range of effects may be observed. Of the data sources available, hospital records provided the most complete picture of accident injuries within a community. These were usefully supplemented by police data on RTAs. The weight of evidence from the Canadian research and the factory studies in the U.K. supports the hypothesis that first aid training reduces the likelihood that trainees will suffer accident injuries during a period of time following the training. However, in the present study the problem of not having injury accident data linked to individuals means that we cannot conclude that there has been any direct effect of the training. However, the evidence relating to reported decreases for workplace accident injuries and for males aged between 21 and 40 years is not inconsistent with support for this from earlier studies. Despite the existence of independent sources of data on RTAs and associated injuries, the evidence on effects in this location is poor and the data may be subject to large amounts of error. However, the RTA evidence is strongly supportive of the NSRI data, giving more confidence to each set of findings. This study strongly supports the hypothesis that first aid-trained persons can influence the likelihood that others close to them, especially those aged 15 years and under, will have reduced accident injury rates for a period of time after training. These indirect effects of first aid training are attributed mainly to the influence of trained parents and teachers upon young people at home and in school. Further controlled studies on individuals are needed to confirm or to refute this hypothesis. The relative lack of control over a community environment in a research study means that there remains a possibility that factors other than the first aid training were operating. However, our own initial "scientific scepticism" that we might not be able to. detect any effects of the training and our subsequent failure to find any other explanation for our results both go some way towards rejecting this possibility. Therefore, the conclusion must be that a community will benefit from having a relatively large percentage of persons trained in emergency first aid. It seems likely that such detectable benefits of widespread community first aid training will be enhanced if the training is concentrated upon those members of the community who have the greatest opportunity to influence both a substantial part of the environment and some aspects of behaviour of others. In particular, emphasis might be placed upon the training of parents, especially mothers and others in the 21-40 years of age group.
Acknowledgements At the time of undertaking the work upon which this paper is based, both authors were research fellows in the Department of Occupational Health and Safety at the University of Aston in Birmingham. The authors wish to record their grateful acknowledgement of the sponsorship and support of St John Ambulance in the research described in this paper. References 1. St John Ambulance (1938). Canadian First Aid. Ottawa: St John Ambulance, Priory of Canada. 2. Miller, G. & Agnew, N. (1973). First aid training and accidents. Occupational Psychology 47, 209-18.
Impact o f Community First A i d Training
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3. Hunt, R. N. (1977). Peace River Region FACTS Project, Final Statistical Report. Alberta: Grande Prairie Regional College. 4. McKenna, S. P. (1978). The effects of first aid training on safety: a field study of approaches and methods'. Birmingham: The University of Aston (Ph.D. thesis). 5. McKenna, S. P. & Hale, A. R. (1981). The effects of emergency first aid training on the incidence of accidents in factories. Journal of Occupational Accidents 3, 101-14. 6. McKenna, S. P. & Glendon, A. I. (1980). First aid training: can it help prevent accidents? Sqfety Surveyor 8, 22-8. 7. McKenna, S. P. & Hale, A. R. (1982). Changing behaviour towards danger: the effect of first aid training. Journal of Occupational Accidents 4, 47-60. 8. Glendon, A. I. & McKenna, S. P. (1979). First Aid Community 7Yaining: FACT(UK), Finalyear Report to the Sponsor. Birmingham: The University of Aston. 9. Siege•, S. ( • 956). N•nparametric Statistics f•r the Behavi•ural Sciences. New Y •rk : McGraw-Hi••. 10. Office of Population Censuses and Surveys (1971-79). Monitor. London: O.P.C.S. 1l. Denzin, N. K. (1970). The .Research Act in Sociology: a Theoretical Introduction to Sociological Methods. Sevenoaks: Butterworths. 12. NichoU, J. P. (1981). The usefulness of hospital inpatient data. In Road Safety: research and practice. (Foot, H. C., Chapman, A. J. & Wade, F. M., Eds) (1981). Eastbourne: Praeger, 19-25. 13. Bull, J. P. & Roberts, B. J. (1973). Road accident statistics: a comparison of police and hospital information. Accident Analysis and Prevention 5, 45-53. 14. Woodward, A. (1981). Motor cycle accidents: routinely collected data and opportunities jot prevention. Nottingham: The University (M. Med. Sci. thesis). 15. Shinar, D., Treat, J. R. & McDonald, S. T. (1983). The validity of police reported accident data. Accident Analysis and Prevention 15, 175-91. 16. Boyle, A. J. (1981). Statistical and simulation studies of accident susceptibility in industrial tasks. London: The University (Ph.D. thesis). 17. Glendon, A. I. & McKenna, S. P. (1982). Catching them young. Occupational Health 34, 517-20. 18. Powell, P. I., Hale, M., Martin, J. & Simon, M. (1971). 2000 Accidents: a Shopfloor Study of Their Causes. Lodon: National Institute of Industrial Psychology, Report 21. 19. Richer, M. (1973). Factors affecting the incidence of accidental injuries in manuJacturing industry. Birmingham: The University (Ph.D. thesis).
Using Accident Injury Data to Assess the Impact of Community First Aid Training A. lan Glendon
Appfied Psychology Division, Management Centre, The University of Aston in Birmingham, Gosta Green, Birmingham, B4 7ET Stephen P. McKenna
MRC/ESRC Social and Applied Psychology Unit, Department of Psychology, The University, Sheffield $10 2TN
In a U.K. First Aid Community Training Project from a town with a population of around 19,000 over 1200 people took a 4-h emergency first aid course. Independent evidence for the effects of the training was obtained from hospital casualty registers and from police road traffic accident data. The data indicated that the first aid training significantly reduced the accident injury rate in the community. Age, sex and accident location effects are discussed with reference to the disaggregated empirical data. It is argued that there are substantial indirect effects from the training, particularly the influence of first aid-trained adults upon children, as well as direct effects upon trained individuals shown by earlier studies. Introduction The treatment benefits of first aid training are well known and accepted. Modern first aid was " i n v e n t e d " about a century ago to help the victims of accidents and sudden illness when qualified medical aid was not available. Training is designed to equip people with the skills necessary to maintain life, reduce suffering, prevent the condition worsening and to help promote recovery. However, as long ago as 1938 it was thought that as well as being an emergency measure, first aid training was a means of accident prevention? Systematic study of the hypothesis that first aid is a means of accident prevention began in Canada in 1969 and in the U.K. in 1973. The work concentrated upon evaluating changes in accident injury rates following first aid training. F r o m this research, particularly in the U.K., much has been learnt of the process linking first aid training, safer behaviour and reductions in accident rates. Canadian research indicated that first aid training was associated with safer driving behaviour 2 and with a reduction in road traffic accident rates? To overcome problems associated with the use of retrospective and cross-section data, prospective studies of workers who attended 4-h courses in emergency first aid training at two factories were carried out. 4, 5 The course, in which technical terms and jargon were eschewed, concentrated upon essential life-saving treatments, and explanations were kept as simple as possible. As much practical work as possible was included, and trainees were required to demonstrate their ability to carry out life-saving techniques effectively. The results showed that, contrary to expectation, in the period prior to training the group which volunteered for training had a worse accident injury frequency rate than a matched control group. Evidence from subject interviews before and after training suggested that 0033-3506/85/020098-F 12 $02.00/0
~ 1985 The Society of Community Medicine
Impact of Community First Aid Training
99
this finding was not the result of differences in willingness to report injuries. It is possible to speculate that people who have more experience of accidents may perceive a greater need for learning how to treat the injuries which result from them. In the post-training period, when compared with the baseline of accident injury frequency in the control group, there was a statistically significant reduction in the reported accident injury frequency of the first aid-trained group. 4,5 It has been suggested that first aid training increases motivation to avoid injury), 7 Following the factory studies, further questions seemed worthy of study. First, "is it possible to generalize factory-based findings to other settings?" Second, " i f so, is it possible to assess the effectiveness of the training in a whole community where data are less easy both to collect and to interpret?" Third, "are the motivational benefits of first aid training confined to those trained, or do trainees also influence others' environment or possibly their behaviour?" A major reason for selecting a community for study was to test the hypothesis that there would be indirect effects of the training upon accident injury rates of those who had not themselves received first aid training. The methodological difficulties of researching a community need to be weighed against extending the benefits of first aid training demonstrated in the factory studies to a whole community, where there is much greater scope for accident injury reduction. In an attempt to answer these and other questions, a community study was carried out in Leek, Staffordshire. Among other reasons, this town was selected because of its relative isolation from other urban centres, its range of industries and the limited employment migration to and from the town. These selection factors meant that data sources could be directly linked to the population receiving training. However, it was not possible to record the names of injured individuals directly because of the confidentiality of medical records, and hence it was not possible to specify the accident performance of trainees. The combination of the matched control (the factory studies) with field studies which incorporate a quasi-experimental design allows for a balanced approach which can strengthen findings from any single method. Method
A total of 120 courses were run in Leek over a 27-month period and 1204 people took either all or part of the course. The standard 4-h course was taught by a small team of specially trained, experienced St John Ambulance instructors. The course was the same as that developed during the factory studies and is described elsewhere), 5 Seventy per cent of the trainees lived in Leek itself and most of the remainder came from nearby villages. Attitudinal and other effects of the first aid training were measured through postal surveys conducted before and after the first aid training programme. Accident injury data were collected from hospital casualty registers and from police road traffic accident (RTA) records. The North Staffordshire Royal Infirmary (NSRI) is 13 miles from Leek and has a 24-h accident and emergency service. The total catchment area of the NSRI has a population of approximately 650,000 people. From the NSRI, data were collected on monthly totals of numbers of accident injuries treated, and for Leek residents additional information on the injured individual and location of accident was also collected. Police RTA records enabled a comparison to be made between inj ury accidents occurring in the Leek area and those occurring in the rest of Staffordshire (from the beginning of 1974 - the date of the most recent county boundary changes). Three categories of RTA data are used by police in the U . K . - fatal accidents, other-injury accidents and damage-only
100
A. I. Glendon and S. P. McKenna
TABLE1. A comparison of accident injuries treated at the North Staffordshire Royal Infirmary (NSR1) sustained by Leek residents and all others in the hospital catchment area over two equal periods of time No. of accident injuries 26-Month periods
Leek
Rest of NSRI catchment area
Prior to first aid training in Leek Post first aid training in Leek Percentage change
1861
122,896
1671
128,659
- 10.2%
+ 4.7 ~,
y~ = 10.25, d.f. = 1, P < 0.01. Source: NSRI Casualty Register 1974-1979.
accidents. Damage-only accidents were excluded from this study mainly because these would be subject to the greatest amount of under-reporting and therefore be the least accurate of the three categories. T o o few fatal accidents occur to reveal significant changes over the relatively short time periods available. Therefore, the numbers of fatal accidents and other-injury accidents were aggregated to form the basis for R T A comparisons.
Results (1) Table 1 compares the numbers of accident injuries sustained by Leek residents with those from the rest of the North Staffordshire Royal Infirmary (NSRI) catchment area who were treated at the N S R I during two periods of 26 months - the first prior to the first aid training in Leek and the second during and after completion of the training exercise. Both periods, which were not contiguous, began on 1 January. These are the longest comparison periods available since the most recent county boundary changes. It can be seen that the number of accident injuries to Leek residents treated was 10-2% lower in the second period, while the number of accident injury treatments to people from the rest of the N S R I catchment area was 4-7% higher. This difference was statistically significant (P < 0.01). Table 2 shows the number of road traffic injury accidents occurring in the Leek area and in the rest of Staffordshire during the same two 26-month periods as were used for the N S R I data. It can be seen that the number of injury RTAs occurring in the Leek area was 3- 5 % higher in the second period, while the number of injury RTAs in the rest of Staffordshire was 14.8% higher, which is statistically significant (P < 0.05, one-tailed). A one-tailed test is justified on the grounds that previous research had shown that first aid training is associated with an improved injury R T A record), "~
Discussion (1) The highly significant findings shown in Table l indicate a marked reduction in the number of Leek residents seeking emergency treatment for accidents at the N S R I during the period following the community first aid training. The R T A data show that between the same two time periods the increase in the fatal and other road traffic injury accident
Impact of Community First Aid Training
101
TABLE2. A comparison of road traffic accidents involving injury in Leek and the rest of Staffordshire over two equal periods of time No. of injury road traffic accidents 26-Month periods Prior to first aid training in Leek Post first aid training in Leek Percentage change
Leek
Rest of Staffordshire
678
9068
702
10,413
+ 3-5~
+ 14,8~o
X2 = 3.35, d.f. = 1, P < 0.05 (one-tailed). Source: Staffordshirepolice and Leek police road traffic accident data 1974-1979. rate for the Leek area was less marked than that for the control area. The results obtained from these independent sets of data require examination in order to determine what factor or factors might be operating. Before reviewing out hypotheses in the light of the results obtained, it is first necessary to consider factors which might be expected to provide possible explanations (other than the first aid training) for the findings. Our first task is to attempt to account for the statistically significant improvement in accident injuries to Leek residents reported to the NSRI. The following explanations for the N S R | result may be postulated. (1) There was a sudden relative decrease in the Leek population during the study. This was disproved by a search of the relevant Office of Population Censuses and Surveys Monitors, which revealed that the populations of both areas remained fairly stable. 1° (2) People trained in first aid were not having fewer accident injuries, but were simply treating themselves and others who were injured, thus avoiding the need for hospital treatment. The N S R I receives mainly seriously injured casualties and thus, even if such casualties had received first aid, they would still require further medical treatment. The first aid courses stressed the need to seek qualified medical aid promptly for potentially serious injuries. It has been found that following first aid training, workers claimed that they were more willing to report injuries?, 7 I f valid for the community, this finding would lead to an increase in the number of accident injuries reported. (3) There was some special factor operating in Leek which made it a " s a f e r " place and that this happened to coincide with the first aid training. In all our close connections with the town before, during and after the research period, we never encountered any other factor that could conceivably account for the observed accident injury reductions. Contact extended to interviews with nearly all local general practitioners and hospital staff, district community physicians, police road traffic safety staff, members of St John Ambulance, local newspaper staff and other citizens. (4) There was a publicity effect of the research project upon the community which influenced the observed accident injury rates. There was publicity about the project in the local press, on local radio, in the regional press, through posters and at the Leek Annual Show. But, as in the courses themselves, this publicity made no reference to safety or to accident reduction and was directed towards recruiting trainees.
102
A. L Glendon and S. P. McKenna
(5) Our own large-scale postal surveys affected accident rates within the town. Questionnaires were distributed to half of the households in Leek prior to the training and to a larger number after the training. Hospital data collected subsequent to the second comparison period do not support a hypothesis of a systematic biasing effect from the questionnaire surveys. (6) The total number of accident injuries did not decrease, but these became less serious, perhaps because some at least were treated more promptly than before or because less serious injuries were more accurately diagnosed. This suggests that a reduction in accident injuries to Leek residents reported to the N S R I might correspond to an increase in those reported to the local Cottage Hospital, which treats minor injuries between 0800 and 2000 h. However, data from the Cottage Hospital (not reported here) do not support this hypothesis because there was no significant difference between injury treatments to Leek residents and to non-Leek residents between the same two time periods. The research principle of data triangulation upholds the importance of seeking evidence from more than one source to test a hypothesis, 11 and we therefore turn next to consider the quality of the evidence provided by the R T A data. There are a number of problems associated with using R T A data as a measure of changes in the road user behaviour in this and other studies.* In order to have confidence in the R T A data, certain assumptions have to be made, in particular that any errors occurring would be random and constant over time between Leek and the comparison area. While these are major assumptions and mean that the R T A data are not conclusive in themselves, the fact that the trends observed are similar to those found for the N S R I accident injury data means that the R T A data do provide supportive evidence for the N S R I findings. Having discussed all likely alternative explanations for the observed improvement in accident injury rates, we have confirmed the hypothesis implied in our first question, that it is possible to show reductions in accident injury rates resulting from first aid training within a community as well as within a factory. Evidence that first aid training influenced the accident injury rate in Leek at the time of the study is very strong. However, a problem remains which cannot be explained by the data presented. This concerns the size of the effect from the first aid training upon recorded accident injury rates. Even allowing for the possibility that volunteers for the community training had a worse pretraining accident injury rate than did non-volunteers, 1°, 5 considering that approximately 6 ~ of Leek citizens were trained in first aid, the size of the reduction (over 10~o ) in accident injury rate is much larger than could be expected solely from improvements among those trained. Previous studies ~,5 found reductions in injury accident rates of up to 30-40~o among those trained in first aid, but even if it is assumed that similar reductions for trainees occurred in this community, there is still a large residual reduction to be accounted for. F r o m the data in Table 1, it may be calculated on the basis of expected numbers of accident injuries that there were 377 fewer of these in Leek than would have been expected in the post-training period. I f the most optimistic figure from previous studies of a 4 0 ~ reduction in accident injuries to trainees as a direct result of first aid training is assumed, this only reduces the total by 47 accident injuries (1200/19,000 x 1861 x 40 ~o ), leaving 330 to be accounted for. * General problems in the use of RTA data include : inaccuracies in recording,~2under-reporting by up to 40 for some types of accident,TM 14 and errors in police reporting.15 In this study, police RTA data did not specify numbers of people injured in an accident, there was no control over extraneous factors such as holiday bottlenecks or increases in traffic volume, RTA records included accidents to road users who were not Leek residents and the smallest unit avilable for analysis included rural areas surrounding Leek.
Impact of Community First Aid Training
103
This leads to the conclusion that this figure must be due either to trainees affecting the environment or the behaviour of others or to some other factor or factors. The possibility that factors other than the first aid training might have been operating in Leek at the time of the study has already been dismissed. Therefore, this leaves the hypothesis that those trained in the community significantly influenced the environment or the behaviour of others, and that it is this indirect effect of the training which accounts for the residual improvement in the accident injury reduction. In order to test this hypothesis, we turn first to evidence on some of the characteristics of those who received training in the community. F r o m our survey data, a number of differences in the characteristics of volunteers and non-volunteers emerged, s Compared with non-volunteers, volunteers for first aid training were statistically significantly more likely to be: (a) between 21 and 40 years of age; (b) female; (c) in employment; (d) in contact with others in the 15 years and under age group, both at home (as a parent) and at school. We also know that about 2 0 ~ of those trained were between 6 and 15 years of age. The surveys indicated that around half of those trained - both young and old - reported passing on important first aid knowledge to others, particularly to family members and to workmates or friends, s, 17 Because only 6~o of Leek residents were trained in first aid during the study, we would not expect to find direct effects of the training upon accident injury rates to be very marked for these particular groups. However, we would predict that marked decreases in accident injury rates as an indirect result (trainees affecting the environment or behaviour of others) would be found for those aged 15 years and under and for those aged between 21 and 40 years. In respect of injury accident location we would predict that decreases in accident injury rates as a result of trainees affecting the environment or behaviour of others would be most marked for those accidents occurring: (a) at school; (b) at home; and (c) at work. In order to test the above predictions, it is necessary to return to the N S R I data in disaggregated form. This is done in the following section.
Results (2) In Tables 3-6, missing data are not shown and have been excluded from all analyses. This accounts for the varying column totals in the different tables. Table 3 shows the differences between the two periods of time in numbers of accident injuries sustained by Leek residents of different age groups which were reported to the NSRI. It will be seen from Table 3 that there are statistically significant differences in accident injuries between pre-training and post-training periods for the 5 and under age group (P < 0-001) as well as for the 6-15 (P < 0.001) and 21-40 (P < 0.005) years of age groups. The corresponding differences for the remaining age groups are not statistically significant. A further breakdown of these data to show sex of injured person is shown in Table 4. The data in Table 4 show statistically significant differences in reported accident injuries for both males (P < 0.01) and females (P < 0.05) in the 5 and under age group, but for males only in the 6-15 (P < 0.01) and in the 21-40 (P < 0.05) years of age groups. The data for sex of injured person, including cases where age was not recorded, are not shown, but statistical analysis indicates no significant difference directly associated with sex of injured person. D a t a on location of the accident which resulted in injury for the same two time periods are shown in Table 5. F r o m the data in Table 5 it will be seen that there are statistically significant differences in reported injuries between the two time periods for home accidents (P < 0.001), for work
104
A. I. Glendon and S. P. M c K e n n a
TABLE3. Differencesin number of accident injuries reported to the North Staffordshire Royal Infirmary during two 26-month periods, by age group No. of accident injuries Age group (years) 5 (~15 16 20 2140 > 40 Totals
Pre-training period 153 405 217 514 550 1839
Post-training period
Expectednumbers post-training
94 317 224 449 566 1650
123-5 361 220-5 481.5 558
y2 value
P
14.09 10.73 0.11 4.39 0.23
< 0.001 < 0.001 N.s. < 0.005 N.s.
accidents (P < 0-01) and for accidents at school (P < 0-001), where fewer were reported in all cases. There is also a statistically significant difference in reported leisure accident injuries (P < 0-001), where more accidents occurred in the second time period. It is possible to obtain more detailed information by cross-tabulating accident location with age group. This breakdown is shown in Table 6. Some of the age categories have been combined in order that statical analyses may be performed. The data in Table 6 show that in the home location there are statistically significantly fewer reported accident injuries to those in the two youngest age groups (P < 0'01 and P < 0-001) in the second time period. For the work location, there is a lower incidence of accident injuries (P < 0.01) reported by those in the 21-40 years of age group following the first aid training. A significantly higher incidence of reported leisure accident injuries is found for all but the two youngest age groups. There are also statistically significant changes in reported accident injuries in the street, with those aged over 40 years reporting more (P < 0.05), and in all types of RTAs, where those aged 16-20 years report more accident injuries (P < 0-05).
Discussion (2) The statistically significant results obtained from the data disaggregated by age groups provide strong support for the hypotheses concerning the distribution of the accident injuries among the various age groups. The age groups 5 years and under, 6-15 years and 21-40 years all showed statistically significant reductions in reported accident injuries between the two time periods. Further disaggregation of these data by sex of injured person shows similar patterns for both males and females in the two youngest age groups, although only the reduction for males is statistically significant for the 6-15 years of age group. However, the 18.8% reduction for females in this age group does not fall far short of the 23-2% reduction for males in the 6-15 age group. As the youngest person to take a community first aid course was aged seven years, any changes in the number of accident injuries to those younger than this can only be attributed to the influence of others. As 262 (22%) of those taking a course were aged between 7 and 15 years, it is possible that some of the improvement in accident injury rates for this age group would be attributable to the direct influence of the training, but that a larger effect would be from parents, teachers and perhaps peers. It seems most likely that there is a marked indirect effect whereby first aid-trained parents influence the environment and
Impact of Community First Aid Training
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A. I. Glendon and S. P. M c K e n n a
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TABLE 5. Accident location of injuries to Leek residents reported to the NSRI in two periods of time Accident injuries in pre-trainlng period
Accident injuries in post-training period
Home Work Leisure School Street R T A - all types
582 310 254 85 151 125
438 244 391 46 158 137
Totals
1507
1414
Location of accident
Expected numbers post-training 510 277 322.5 65-5 154.5 131
y~ value 20-33 7.86 29.10 11-61 0.16 0.55
P < < < <
0-001 0.01 0.001 0-00t N.s. N.s.
TABLE 6. Cross-tabulations of age group with location of accident resulting in injury reported by Leek residents to the NSRI in two periods of time
Location
Age group (years)
Accident injuries in pre-training period
Accident injuries in post-training period
Expected numbers post-training
X2 value
P
Home
~< 5 6-15 16-20 21~40 > 40 Totals
97 105 34 98 248 582
60 46 25 87 220 438
78.5 75.5 29.5 92.5 234
8.72 23.05 1.37 0.65 1.68
< 0.01 < 0.001 N.s. r~.s. y.s.
Work
16-20 21~40 > 40 Totals ~< 5 6-15 16-20 21M0 > 40 Totals
50 162 98 310 11 115 37 69 22 254
40 115 89 244 17 140 63 99 72 391
45 138.5 93.5
1.11. 7.97 0.43
N.s. < 0.01 r~.s.
14 127.5 50 84 47
1.29 2.45 6.76 5-36 26.60
N.s. N.s. < 0.01 < 0-05 < 0.001
< 20 ~< 15 16-20 21~40 > 40 Totals
85 51 25 31 44 151
46 47 15 31 65 158
65.5 49 20 31 54'5
11.61 0-16 2.50 0"00 4-05
< 0.001 N.s. N.S. N.S. < 0"05
~< 15 16-20 21M0 > 40 Totals
22 33 40 30 125
14 51 38 34 137
18 42 39 32
2-29 3.86 0.05 0.25
N.s. < 0,05 N.s. y.s.
Leisure
School Street
RTA-all types
Impact of Community First Aid Training
107
behaviour of their children so that they have fewer accident injuries. It is also likely that there is a similar effect from teachers and others in the school environment. The other statistically significant finding which accorded with the hypothesized effect was that males in the 21-40 years of age group had fewer accidents in the post-training period, while this was not true for females in the same age group. Even if there is a small direct effect of training for this group, the larger part of the decrease must be explained by indirect effects, that is, of first aid-trained adults influencing the environment and behaviour of males in this age group. The finding that females did not show a greater accident injury rate red uction than males between the two periods, given the other findings from the disaggregated data, is not surprising, for it does seem that any direct effects would be diffused among all those who received training, while indirect effects tend to be concentrated upon particular age groups and in particular environments. Further evidence for the existence of indirect effects emerges from the considerable variation between injuries disaggregated on the basis of accident location. The statistically significant results obtained from the data shown in Table 5 enable us to accept the hypotheses on changes in accident injury rates for different locations between the two time periods. Thus the three accident locations showing statistically significant decreases in accident injuries are those predicted, namely: school, home and work. The effects of the school and home environments appear to be much larger, reinforcing the notion of the importance of indirect effects by trained people upon others in these environments. The reduction in workplace accident injuries is too large to be accounted for by direct effects of the training upon trainees, and it thus seems likely that there is also an indirect effect through trained work people influencing either the work environment or the behaviour of their colleagues and workmates. Changes in total numbers of street accident injuries and RTA injuries reported during the two time periods were not statistically significant. For leisure activities, where opportunities to influence either the environment or behaviour of others by personal intervention are less, a reverse effect is found with no significant difference for those aged 15 years and under, but statistically significant increases in reported accident injuries for those in the groups aged 16 years and over. It is likely that opportunities for influencing either the environment or the behaviour of others in either the road, street or leisure environments are likely to be less numerous and more transient than in the home, school and work environments, where personal, familial and social ties are likely to be much stronger factors. The findings on accident location are therefore consistent with the hypothesized indirect effects, and suggest that these are likely to be due to making places " s a f e r " rather than by making behaviour "safer". The findings from the work environment confirm that, while fewer accident injuries are reported for all three working age groups during the second period, it is only for the 21-40 years of age group that the change is statistically significant. The major influence hypothesized is indirect effects of first aid-trained workers upon the work environment of their colleagues, and that the effect is only strong enough to influence the peer group with respect to age. For the other working age groups, any indirect effects may be swamped by other factors. 18,19 In the case of street injuries the over-40 years of age group was the only one to experience more, while for RTA injuries the 16-20 years of age group had significantly morel In the light of the indirect effect hypothesis, it is instructive to observe that people from these two age groups were both less likely to volunteer for the first aid training and less likely to be subject to the influence of others who had been trained.
108
A. I. Glendon and S. P. McKenna
Conclusions The study described provides strong independent support for the carefully controlled studies carried out in factory environments. It has also been demonstrated that by extending the scope of such research beyond the strict experimental setting a greater range of effects may be observed. Of the data sources available, hospital records provided the most complete picture of accident injuries within a community. These were usefully supplemented by police data on RTAs. The weight of evidence from the Canadian research and the factory studies in the U.K. supports the hypothesis that first aid training reduces the likelihood that trainees will suffer accident injuries during a period of time following the training. However, in the present study the problem of not having injury accident data linked to individuals means that we cannot conclude that there has been any direct effect of the training. However, the evidence relating to reported decreases for workplace accident injuries and for males aged between 21 and 40 years is not inconsistent with support for this from earlier studies. Despite the existence of independent sources of data on RTAs and associated injuries, the evidence on effects in this location is poor and the data may be subject to large amounts of error. However, the RTA evidence is strongly supportive of the NSRI data, giving more confidence to each set of findings. This study strongly supports the hypothesis that first aid-trained persons can influence the likelihood that others close to them, especially those aged 15 years and under, will have reduced accident injury rates for a period of time after training. These indirect effects of first aid training are attributed mainly to the influence of trained parents and teachers upon young people at home and in school. Further controlled studies on individuals are needed to confirm or to refute this hypothesis. The relative lack of control over a community environment in a research study means that there remains a possibility that factors other than the first aid training were operating. However, our own initial "scientific scepticism" that we might not be able to. detect any effects of the training and our subsequent failure to find any other explanation for our results both go some way towards rejecting this possibility. Therefore, the conclusion must be that a community will benefit from having a relatively large percentage of persons trained in emergency first aid. It seems likely that such detectable benefits of widespread community first aid training will be enhanced if the training is concentrated upon those members of the community who have the greatest opportunity to influence both a substantial part of the environment and some aspects of behaviour of others. In particular, emphasis might be placed upon the training of parents, especially mothers and others in the 21-40 years of age group.
Acknowledgements At the time of undertaking the work upon which this paper is based, both authors were research fellows in the Department of Occupational Health and Safety at the University of Aston in Birmingham. The authors wish to record their grateful acknowledgement of the sponsorship and support of St John Ambulance in the research described in this paper. References 1. St John Ambulance (1938). Canadian First Aid. Ottawa: St John Ambulance, Priory of Canada. 2. Miller, G. & Agnew, N. (1973). First aid training and accidents. Occupational Psychology 47, 209-18.
Impact o f Community First A i d Training
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3. Hunt, R. N. (1977). Peace River Region FACTS Project, Final Statistical Report. Alberta: Grande Prairie Regional College. 4. McKenna, S. P. (1978). The effects of first aid training on safety: a field study of approaches and methods'. Birmingham: The University of Aston (Ph.D. thesis). 5. McKenna, S. P. & Hale, A. R. (1981). The effects of emergency first aid training on the incidence of accidents in factories. Journal of Occupational Accidents 3, 101-14. 6. McKenna, S. P. & Glendon, A. I. (1980). First aid training: can it help prevent accidents? Sqfety Surveyor 8, 22-8. 7. McKenna, S. P. & Hale, A. R. (1982). Changing behaviour towards danger: the effect of first aid training. Journal of Occupational Accidents 4, 47-60. 8. Glendon, A. I. & McKenna, S. P. (1979). First Aid Community 7Yaining: FACT(UK), Finalyear Report to the Sponsor. Birmingham: The University of Aston. 9. Siege•, S. ( • 956). N•nparametric Statistics f•r the Behavi•ural Sciences. New Y •rk : McGraw-Hi••. 10. Office of Population Censuses and Surveys (1971-79). Monitor. London: O.P.C.S. 1l. Denzin, N. K. (1970). The .Research Act in Sociology: a Theoretical Introduction to Sociological Methods. Sevenoaks: Butterworths. 12. NichoU, J. P. (1981). The usefulness of hospital inpatient data. In Road Safety: research and practice. (Foot, H. C., Chapman, A. J. & Wade, F. M., Eds) (1981). Eastbourne: Praeger, 19-25. 13. Bull, J. P. & Roberts, B. J. (1973). Road accident statistics: a comparison of police and hospital information. Accident Analysis and Prevention 5, 45-53. 14. Woodward, A. (1981). Motor cycle accidents: routinely collected data and opportunities jot prevention. Nottingham: The University (M. Med. Sci. thesis). 15. Shinar, D., Treat, J. R. & McDonald, S. T. (1983). The validity of police reported accident data. Accident Analysis and Prevention 15, 175-91. 16. Boyle, A. J. (1981). Statistical and simulation studies of accident susceptibility in industrial tasks. London: The University (Ph.D. thesis). 17. Glendon, A. I. & McKenna, S. P. (1982). Catching them young. Occupational Health 34, 517-20. 18. Powell, P. I., Hale, M., Martin, J. & Simon, M. (1971). 2000 Accidents: a Shopfloor Study of Their Causes. Lodon: National Institute of Industrial Psychology, Report 21. 19. Richer, M. (1973). Factors affecting the incidence of accidental injuries in manuJacturing industry. Birmingham: The University (Ph.D. thesis).