Trauma Responders Unify to Empower Communities in Santa Cruz, Bolivia: Course Participants and their Feedback

INTRODUCTION

Trauma and surgical emergencies contribute significantly to the global burden of disease, and the incidence has been increasing over the last 16 years.¹ Approximately, 5.8 million people die each year secondary to trauma and resulting injuries, with 90% of those deaths occurring in low- and middle-income countries (LMICs).^2–4 In some LMICs, prehospital trauma mortality approaches 40–50%.^5–8 Specifically in Bolivia, injuries accounted for 6,500 deaths or 9.5% of all-cause mortality and 383,000 or 11.5% of disability-adjusted life years in 2016, with the death toll increasing each year.⁹

Coordinated prehospital system implementation, including ambulance coordination and first responder skill trainings, can reduce prehospital mortality, both in high-income and low-income settings. Implementation of emergency medical systems and prehospital services faces numerous obstacles, including deficits in financial, infrastructural, and human and technical resources, in addition to poor distribution and underutilization of existing assets.^10,11 Nevertheless, reductions in short- and long-term morbidity and mortality are observed with implementation and successful maintenance.^10–14 A meta-analysis examining prehospital trauma systems in LMICs demonstrated a 25% decreased risk of mortality for trauma patients in areas with a prehospital trauma system.¹⁵ Paramedics, medical first responders, and trained layperson responders are a crucial component to the success of a prehospital system.^11,16 Studies analyzing the effects of paramedic and first responder courses in LMICs demonstrated a reduction in prehospital mortality from 27% to 13.5% and 40% to 14.9%, respectively; these effects were sustained long-term.^7,17,18

Preliminary research in Bolivia demonstrates that trauma first responder courses (TFRCs) significantly improve confidence and skill levels for first responders.^19,20 An 8-hour TFRC pilot that took place in 2013 in La Paz and Potosi, Bolivia, with the majority of participants in the medical field demonstrated an improvement in knowledge from 48% to 76% and an increase in confidence on a 5-point Likert scale improving from 4 to 4.5.¹⁹ A modified and condensed version of the course was piloted in Santa Cruz de la Sierra, Bolivia, in November and December 2018 to a majority layperson audience. Similar and significant improvements in knowledge (33% pretest vs 59% posttest) and first aid provision confidence (3.65 pre-course to 4.5 post-course) occurred.²⁰ Knowing the course to be effective, wider dissemination ensued in partnership with the Santa Cruz Municipal Government.

While the effectiveness of these courses and the impact on trauma morbidity and mortality is established, limited information exists in the literature regarding participant characteristics and course feedback. A better understanding of participant demographics and current safety behaviors could allow for more tailored course content potentially maximizing short- and long-term information retention. We hypothesize the resulting demographic and feedback analysis to provide a structure for course modification, improved teaching strategies, and more advanced course development.

MATERIALS AND METHODS

Trauma responders unify to empower (TRUE) the community is an evidence-based, bystander trauma first aid training course developed by surgeons and community members for use in an urban, US city.²¹ The TRUE course and the 8-hour pilot TFRC in Potosi and La Paz¹⁹ were utilized to develop a condensed didactic and practical TFRC in Spanish: TRUE-Bolivia.

Course participants were recruited in Santa Cruz, Bolivia, with the assistance of the state-level Department of Health, the municipal-level urban mobility branch of government, and a local university. In the recruitment material, the course was advertised to all community members, including medical providers, students, police, firefighters, and laypersons. Direct communication with community leaders, flyers, and WhatsApp messages were used to recruit participants. No participants were excluded in the recruitment phase. All participants signed a written or virtual consent upon enrolling in the course.

TRUE-Bolivia takes place over 2 days with a 2-hour didactic session and a 2-hour practical session. The didactic session includes the written consent, a 12-item baseline demographic survey, and a 9-question pre-course knowledge assessment. It also includes an hour lecture that covers universal precautions, scene safety, safe victim transfers, basic airway management, bleeding control, and pelvic binding. The practical session includes four hands-on skill stations, a nine-question post-course knowledge assessment, and a course evaluation. Participants who completed all pre- and post-course assessments were included in this study. Participants who only attended one session or who did not complete all four of the evaluations were excluded.

The baseline demographic assessment is distributed virtually or by hand, and all other assessments are completed by hand in person. After completion of the course, the assessments are coded and de-identified. For this study, SAS v9.4 was used to perform Chi-square analyses. Qualitative data were analyzed and coded by thematic content. Primary outcomes of the study include providing descriptive analytics of the characteristics of the participants in this course and their feedback. Secondary outcomes included examining how safety behaviors, previous trauma experiences, and feedback provided varied based on participant occupation. This study was approved by the Northwestern Institutional Review Board and the local Department of Health.

RESULTS

Between November 1, 2018, and September 30, 2019, 18 courses took place. While 418 participants enrolled in the course and attended at least one session, 269 participants (64%) completed the entire course, attending both the didactic and practical sessions and completing all pre- and post-course assessments. There were an average of 15 people in each session.

DISCUSSION

This descriptive review is one of the first of its kind taking an analytic approach to understanding the composition of course participants in a trauma first-aid course and interpreting their feedback. Demographic analysis demonstrates the majority of participants are young males with primary- and secondary-level education working in transportation. Considering this course was adapted from previous courses in Chicago and other cities in Bolivia, the authors were interested to determine whether the courses reached different demographics. Compared with TRUE-communities participants in Chicago with a population average age in their 20s and 39.7% male participants²¹ and the TFRC in La Paz and Potosi, Bolivia, with an average age of 32 years and 43.6% male,¹⁹ TRUE-Bolivia participants are more predominantly male (78.4%) and older (35.4 years) on average. The participants in Chicago are mostly recruited through community groups with courses taking place in high schools while the TFRC in La Paz and Potosi was predominantly with medical professionals (88%). The majority of participants being public transportation drivers in our study population likely accounts for these differences.

Similar to a first-aid course provided to taxi and bus drivers in Ghana,²² the majority of participants in this TRUE-Bolivia study completed a primary or secondary level of education, and 88.8% witnessed a prior traumatic event (almost identical to the 88% in the Ghanaian study). Interestingly, only 13% of participants in the Ghanaian study had prior first-aid training vs 37.5% of TRUE-Bolivia participants. However, 82% of Ghanaians provided assistance at the scene of the witnessed traumatic event compared with 43.7% of TRUE-Bolivia participants. There is likely a multifactorial explanation for this great difference in providing first aid at the scene. TRUE-Bolivia participants reported not only a lack of knowledge and other obligations preventing them from providing first aid but also reported legal fears. Medicolegal consequences have been a reoccurring concern during didactic sessions in multiple courses. In Ghana, a Good Samaritan law exists to protect laypersons in case an error occurs during the provision of first aid on the scene, but no laws or equivalent protections exist in Bolivia. Moreover, at times, police implicate bystanders in the incident or the injury of the victim, which serves as a serious disincentive to assist, similar to another study that identified medicolegal issues as a barrier to providing emergency care in Uganda.²³ Our study suggests enacting protective legislation may be beneficial to improve prehospital bystander interventions. At the same time, we are increasing participant confidence and knowledge with signed certificates by the Urban Mobility Sector of the Municipal Government to empower participants to assist victims at the scene of a trauma within the scope of our course’s instruction.

On post-course evaluation, the overwhelming majority found the TRUE-Bolivia course to be useful and learned skills they would use in the future. Almost all participants mentioned they learned something new and/or felt they would be able to save a life or provide first aid in the future. Similar to TRUE-communities in Chicago where 97.1% of participants would recommend the course to a colleague, 97.7% of participants would recommend the TRUE-Bolivia course. Noting the positive experience of participants in the course and providing the feedback to stakeholders helps sustain the course, improve its distribution, and ensure that the target audience is reached. In an environment like Santa Cruz, Bolivia, where ambulances can take more than an hour to arrive, and trauma accounts for 8 of the top 20 causes of prehospital death,²⁴ a course like TRUE-Bolivia empowers participants to help at the scene of a trauma.

Limitations of this study include those intrinsic to a course with participant attrition and a primarily survey-based study. Only 64% of participants who enrolled or arrived to a portion of the course actually completed the entire course and all four assessments. Therefore, there is an inherent selection bias in the final sample that was included for analysis. While beyond the scope of this study, future investigation will include analyzing statistical differences between these two populations and determining ways to improve participant retention in the course. Next, the baseline demographic survey requests information on safety behaviors or trauma event observations that took place in the last 6 months which can be subject to recall bias. Additionally, the pre- and post-course evaluations are not anonymous at the time of completion (coding takes place after the completion of the entire course), so there is a risk for providing answers that may appease study investigators instead of more honest responses that might be affiliated with a truly anonymous survey. Another limitation of this study is related to longitudinal skills decay. Poor knowledge retention is a well-known phenomenon of didactic courses, and our study does not include a long-term follow-up. Future directions of this study will include a 6–12-month follow-up survey.

CONCLUSION

In conclusion, the descriptive analysis presented here demonstrates that collaboration with local organizations allowed an effective layperson TFRC, TRUE-Bolivia, to be delivered to a population in Santa Cruz, exposed to many trauma incidents, but lacking knowledge and/or confidence to provide assistance. Participant feedback assists with course revisions while overall maintaining the focus on trauma prevention and initial victim management. TRUE-Bolivia empowers participants through didactic instruction and practical skill development. The hope is that this course will translate to decreased prehospital morbidity and mortality associated with trauma. Future investigation is needed to evaluate long-term knowledge retention and utilization of learned techniques.

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