Introduction
Despite the various preventive efforts, the burden of injuries caused by road traffic crashes (RTCs) is still high world-wide. It is estimated that 1.35 million people die annually from RTCs, representing 27.7% of all injury-related deaths. Furthermore, as many as 20 to 50 million people suffer from RTC-related disabilities. 1 The mortality rate is three-times higher in low-income countries. In Africa, it is estimated that 26.6 per 100,000 people succumb to RTCs annually. 2 For instance, the fatality rate of RTCs in Rwanda was 22 deaths per 100,000 and 1,173 disability-adjusted life years per 100,000 population. Furthermore, many RTC-related deaths occur at the scene before or within 24 hours of hospital admission. The likelihood of dying from RTC-related injuries increased 2.7-times in the prehospital setting. Reference Kim, Byiringiro and Ntakiyiruta3
In Rwanda, RTCs commonly occur in the capital (Kigali City). Among the various road users, commercial motorcycles are the most common mode of public transportation. Reference Kim, Byiringiro and Ntakiyiruta3–Reference Petroze, Byiringiro and Ntakiyiruta6 Furthermore, the prevalence of RTCs involving commercial motorcyclists in Rwanda ranged from 38.7% to 73.5%. Reference Nickenig Vissoci, Krebs and Meier4,Reference Ingabire, Petroze, Calland, Okiria and Byiringiro7–Reference Zafar, Canner and Nagarajan9 Insufficient knowledge, negative attitudes, and low practice of first aid skills among bystanders and laypersons contributed to the high rate of preventable deaths from potential life-saving injuries. Reference Davis, Satahoo and Butler10,Reference Bakke, Steinvik, Eidissen, Gilbert and Wisborg11 First aid, a rapid and life-saving procedure, should be provided immediately after the RTC while awaiting the arrival of Emergency Medical Services (EMS) to transport the victims to the hospital. Providing first aid is especially important in low- and middle- income countries (LMICs), where EMS is scarce. Besides a shortage of ambulances, most of Rwanda’s road network consists of narrow footpaths with poor access to EMS vehicles. Many RTCs in Rwanda involve commercial motorcyclists, making them the road users most vulnerable to RTC. Therefore, this study aimed to assess the knowledge, attitude, and self-reported practice (KAP) of providing first aid for RTC victims by commercial motorcyclists, to determine the relationship between sociodemographic characteristics and the level of KAP and to evaluate the predicting factors of outcome variables.
Methods
Design
This study was cross-sectional and assessed the KAP of the first aid provision to RTC victims among commercial motorcyclists working in Kigali City in May 2021.
Setting
This study was conducted in Kigali City, the capital of Rwanda. It comprises three districts: Gasabo, Kicukiro, and Nyarugenge, with an area of 730 km 2 and 1,745,555 (13.2%) of Rwanda’s population. 12 Kigali City was selected because it is an urban area with heavy road traffic and a big number of RTCs compared with other provinces of Rwanda.
Sample Size and Sampling Technique
The total population of commercial motorcyclists working in Kigali City was 10,975. 13 A two-sample group proportion was used to calculate the sample size, Reference Lachenbruch, Lwanga and Lemeshow14 using a 95% confidence interval, a 5% margin of error, and a power of 80%. The estimated sample size was 200 commercial motorcyclists after considering the non-response rate of 10%. A stratified sampling technique was used to recruit participants based on the proportions across the three districts.
Questionnaire
A self-administered questionnaire was adopted after obtaining permission from the original developers in the studies conducted in Tanzania. Reference Lukumay, Ndile and Outwater15,Reference Ndile, Lukumay, Bolenius, Outwater, Saveman and Backteman-Erlanson16 The tool was based on World Health Organization (WHO; Geneva, Switzerland) guidelines on essential knowledge and skills required for basic first aid provision. Reference Sasser, Varghese and Kellermann17 The first section of the questionnaire consisted of demographic characteristics and other factors related to first aid KAP. They were age, gender, working place, level of education, year of working experience as a commercial motorcyclist, previous training on first aid, and year they attended. Moreover, previous work, membership of the Red Cross, previous help, number of helped victims, and recognition of the toll-free line to call Service d’Aide Médicale Urgente (SAMU; local EMS) or police in an emergency were asked.
The second section included ten multiple-choice questions assessing the knowledge of RTC first aid, while the third section had five items assessing attitudes on a five-point Likert scale ranging from “strongly disagree” to “strongly agree.” The last part was a scenario-based assessment of the participants’ self-reported first aid practice with four open-ended questions. Items on the questionnaire focused on priority problems in managing injured people, initial victim assessment, infection prevention, hemorrhage control, management of airway and breathing, immobilization of fractures of extremities, position for an unconscious patient, and transportation of the victims.
The questionnaire was translated into Kinyarwanda (the local mother tongue).
Pre-testing was performed on 30 commercial motorcyclists not included in the study’s final analysis. In addition, two emergency physicians and four nurses working in the EMS and lecturers reviewed the questionnaire to check the content validity.
The knowledge level was categorized into poor knowledge with a response rate of fewer than seven questions over ten (<70%), while good knowledge was attributed to seven and above answers over ten (≥70%). This cuff of points referred to previous similar studies. Reference Lukumay, Ndile and Outwater15,Reference Ndile, Lukumay, Bolenius, Outwater, Saveman and Backteman-Erlanson16 The participants’ attitude was classified as positive (strongly agree and agree) or negative (strongly disagree, disagree, and unsure). Then, all the positive attitudes were summed up and considered above the mean value and vice versa. Reference Teshale and Knowledge18 Finally, self-reported practice was stratified into good (above the mean) or poor practice (below the mean). Reference Lukumay, Ndile and Outwater15,Reference Duut, Okyere, Zakariah, Donkor and Mock19
Ethical Considerations
The ethical approvals were obtained from the University Internal Review Board (029/CMH/IRB/2021) and the University Ethic Committee for Research involving Human Subjects (JKEUPM-2021-173). Participants were informed and signed an informed consent to participate voluntarily before data collection. Participants’ identification was anonymous using codes instead of their names, and their responses were confidential.
Data Analysis
SPSS version 25 (IBM Corp.; Armonk, New York USA) was used to analyze the data. Descriptive analysis was used to describe the sociodemographic characteristics and other factors influencing the KAP of first aid provision. A chi-square test was performed to determine the relationship between sociodemographic characteristics and the level of KAP among commercial motorcyclists. A P value less than .05 was considered statistically significant. The multivariate analysis evaluated the relationship between the predictor and outcome variables.
Results
Sociodemographic Characteristics of Participants and Other Related Factors
All 200 commercial motorcyclists completed the questionnaire distributed and were male. Most participants were less than 40 years of age: 164 (82%). The mean age was 34.1 (SD = 5.77) years. Most participants, 167 (83.5%), had less than ten years of working experience. The mean year of working experience was 7.1 (SD = 3.83). Only 35 (17.5%) participants had attended previous first-aid training, and 19 (9.5%) attended it five years ago. Most participants only had primary level education: 148 (74.0%). As for previous work experience, as many as 146 (73.0%) worked in private sectors.
In addition, only 13 (6.5%) of the participants were Red Cross members. One-third of the participants helped at least one-to-five victims before this study. Regarding the emergency contact number awareness to call after an RTC, only 33 (16.5%) knew the correct number of local EMS (SAMU). However, more than one-half, 118(59.0%), knew the police number.
Distribution of Knowledge of Participants
Most participants correctly answered the technique to handle leg fractures at 151 (75.5%), while almost one-half, 97 (48.5%), correctly answered the right way to check for responses to determine whether the victim was unconscious. Only one-third knew how to stop external bleeding: 66 (33.0%). On the other hand, the majority of participants answered incorrectly about the transport of the victim: 177 (88.5%), helping the unconscious victim: 176 (88.0%), and the prioritized problem in the management of RTC victim: 166 (83.0%; Table 1).
Table 1. Distribution of Knowledge of Participants
Distribution of Attitudes of Participants
Most participants, 160 (80.0%), reported positive attitudes towards the role of first aid in improving the chance of survival and the willingness to provide post-RTC first aid: 158 (79.0%). However, negative attitudes were observed concerning the initiation of first aid on scene, 57 (28.5%), in which participants believed they should wait for the arrival of the professionals to prevent infectious diseases (Table 2).
Table 2. Distribution of Attitudes of Participants
Abbreviation: RTC, road traffic crash.
Distribution of Self-Reported Practice of Participants
Table 3 shows that approximately 145 (72.5%) of the participants reported good practices in preventing cross-infection while providing first aid to help the victim. However, most participants reported poor practice on supporting a conscious victim who was not breathing well: 185 (92.5%).
Table 3. Distribution of Self-Reported Practice of Participants
Association between Sociodemographic Characteristics and Other Factors of Participants and their KAP Level
Table 4 shows that previous first-aid training (P = .009), the year they attended first-aid training (P = .018), and education level (P = .028) were statistically associated with participants’ knowledge levels. Likewise, being a member of the Red Cross (P = .039) and awareness of emergency call numbers for police (P = .002). Previous first-aid training (P = .035) and the year the participants attended first-aid training (P = .026) were statistically associated with their attitudes. Moreover, there was a significant association between the self-reported practice of participants with their age group (P = .041), previous first-aid training (P = .025), level of education (P = .002), and membership in the Red Cross (P = .034).
Table 4. Association between Sociodemographic Characteristics and Other Factors of Participants and Their Level of Knowledge, Attitudes, and Self-Reported Practice
Note: The P value was calculated using a chi-square test (P > .05 was statistically significant).
Abbreviation: SAMU, Service d’Aide Médicale Urgente (Emergency Medical Services).
a P > .05 is expressed as statistically significant.
Predictors of Knowledge Attitudes and Self-Reported Practice
All variables were included in the multivariate analysis based on biological plausibility and model fitness principles of variable selection. Previous first-aid training and knowing an emergency call number for the police were predictors of knowledge. The odds of having good knowledge were 3.7-times higher (AOR = 3.7064; 95% CI, 1.379-9.956) among those with previous first-aid training compared to those who never had. Similarly, it was six-times higher (AOR = 6.132; 95% CI, 1.735-21.669) among those who knew police emergency call number compared to those who did not. For attitudes, previous first-aid training was a predictor. The odds of having positive attitudes were three-times higher (AOR = 3.087; 95% CI, 1.033-9.225) among those who attended first-aid training previously compared to those who never did. Finally, age, previous first-aid training, educational level, and number of victims cared for were statistically significant predictors of self-reported practice. The odds of having a good self-reported practice were 60% less (AOR = 0.404; 95% CI, 0.182-0.897) among those less than 40 years old compared to those 40 years and above. In addition, the odds of having good self-reported practice were 2.4-times higher (AOR = 2.410; 95% CI, 1.056-5.499) among those who attended first-aid training previously compared to those who never did. Likewise, the odds of having good self-reported practice were 2.5-times higher (AOR = 2.533; 95% CI, 1.260-5.092) among those with high school and above compared to those who had less than high school level education. Lastly, the odds of having good self-reported practice were 50% less (AOR = 0.523; 95% CI, 0.282-0.969) among those who cared for up to five victims compared to those who never cared for anybody (Table 5).
Table 5. Predictors of Knowledge, Attitudes, and Self-Reported Practice
Abbreviation: SAMU, Service d’Aide Médicale Urgente (Emergency Medical Services).
a P > .05 is expressed as statistically significant.
Discussion
This study assessed the KAP of first aid provision among 200 commercial motorcyclists in Kigali City. The findings showed that all participants were male with a mean age of 34.1 years and a mean working experience of 7.1 years. These results are similar to the studies conducted in Uganda, Kenya, and Tanzania, whereby the mean age was 33.1, 28.4, and 31.3 years, respectively.Reference Delaney, Bamuleke and Lee20–Reference Makota and Kibusi22 In addition, in most African countries, riding a motorcycle as a business is performed typically by young males.Reference Nickenig Vissoci, Krebs and Meier4,Reference Wang, Krebs, Nickenig Vissoci, de Andrade, Rulisa and Staton23–Reference Tumwesigye, Atuyambe and Kobusingye25 This may be due to the nature of work, sometimes working at night, which should not be safe for females. Moreover, the Rwandan proportion of young people below 30 years was estimated at 65.3%.12
Furthermore, this study showed low exposure to first-aid training. Most participants previously worked in the private sector, and their education level was mainly primary school. Similarly, low first aid attendance was found in studies conducted in Chad, Uganda, Tanzania, and India.Reference Makota and Kibusi22,Reference Hancock, Delaney and Eisner26–Reference Ssewante, Wekha and Namusoke28 On the other hand, studies conducted in some developed countries such as Australia, Turkey, and Norway revealed the previous first-aid training rate ranged between 77% and 90%.Reference Arbon, Hayes and Woodman29–Reference Bakke, Steinvik, Angell and Wisborg31 In this study, the low attendance should be linked to the fact that no first aid is found in driving schools as mandatory for learner drivers in the mentioned countries. Considering previous work, in certain lines of work like education and security, first-aid training is provided to the employees to equip them with life-saving skills.Reference Lukumay, Ndile and Outwater15,Reference Joseph, Narayanan and Bin Zakaria32,Reference Adib-Hajbaghery and Kamrava33 In comparison, this study’s participants mostly had previous work experience in the private sector; thus, they had low exposure and access to first-aid training. Regarding the level of education, the same low level was observed in the studies conducted by Makota, Olugbenga-Bello, and Glèlè-Ahanhanzo.Reference Makota and Kibusi22,Reference Olugbenga-Bello, Sunday, Nicks, Olawale and Adefisoye34,Reference Glèlè-Ahanhanzo, Kpade, Kpozèhouen, Levêque and Ouendo35 Controversially, other studies found that around one-half or more participants had secondary school education.Reference Hancock, Delaney and Eisner26,Reference Delaney, Bamuleke and Lee36
This study also considered other factors related to KAP of first aid and found that a limited number of participants were members of the Red Cross. Other studies have also observed the Red Cross’s low affiliation.Reference Hancock, Delaney and Eisner26,Reference Chokotho, Mulwafu, Singini, Njalale, Maliwichi-Senganimalunje and Jacobsen37,Reference Suryanto and Boyle38 In this study, commercial motorcyclists are not participating in Red Cross activities because their job is demanding and time consuming. In addition, there is a lack of public awareness of the importance of prehospital management, and the National Red Cross doesn’t have enough resources to expand its program to everyone.
Furthermore, helping behavior was also evaluated, and more than one-half of the participants helped the victims. The same findings were found among drivers who provided first aid and transported the victims to the hospitals.Reference Glèlè-Ahanhanzo, Kpade, Kpozèhouen, Levêque and Ouendo35,Reference Pallavisarji, Gururaj and Nagaraja Girish39 In contrast, in some studies, participants hesitated to help the victims due to fear of worsening the case and legal proceedings.Reference Teshale and Knowledge18,Reference Heard, Pearce and Rogers40–Reference Regard, Rosa and Suppan42 In this study, the fear of legal jurisdiction and lack of knowledge were witnessed by some participants in case they carried the victims to the health facilities. Therefore, they prefer to wait for ambulance or police to decide before their helping action. Few participants knew the EMS number, while more than one-half knew the police number. SsweanteReference Ssewante, Wekha and Namusoke28 and Glèlè-AhanhanzoReference Glèlè-Ahanhanzo, Kpade, Kpozèhouen, Levêque and Ouendo35 found the same results. In contrast, Pallavisarji and Slabe found that most participants knew the ambulance call number.Reference Pallavisarji, Gururaj and Nagaraja Girish39,Reference Slabe and Fink43 In this study, the discrepancy may be because the police often arrive at the RTC scene before the EMS, and there is a shortage of ambulances compared to police services.
Knowledge
This study highlighted the overall poor knowledge level among most motorcyclists. Similar findings were shown in studies conducted in the Dominican Republic,Reference Arellano, Mello and Clark44 Benin, and Tanzania.Reference Makota and Kibusi22,Reference Glèlè-Ahanhanzo, Kpade, Kpozèhouen, Levêque and Ouendo35 Furthermore, among professional drivers in Ethiopia,Reference Teshale and Knowledge18 Nigeria,Reference Olumide, Asuzu and Kale45 Uganda,Reference Ssewante, Wekha and Namusoke28 and Nepal.Reference Dahal and Vaidya46 In Poland, the gap focused more on providing cardiopulmonary resuscitation among professional and non-professional drivers.Reference Karyś, Rębak, Karyś and Ksroka47 It indicates several countries have a gap in first aid knowledge among primary road users. In this study, the low level of knowledge is likely attributed to the previous gap in knowledge since most participants had only primary school education and never received any first-aid training. First aid courses are not taught deeply in the primary school curriculum and are absent in the driving school teaching program.
Attitudes
Most participants have reported positive attitudes toward the role of first aid in increasing the chance of survival and the willingness to provide post-crash first aid. However, negative attitudes were observed in the initiator of first aid. These findings are consistent with studies that reported the willingness to help among participants.Reference Teshale and Knowledge18,Reference Ssewante, Wekha and Namusoke28,Reference Bakke, Steinvik, Angell and Wisborg31,Reference Heard, Pearce and Rogers40,Reference Saqer48 In Ethiopia and Check Republic, the fear of accident scenes and causing harm to the victim due to inadequate knowledge led to a high preference for not intervening at the scene of RTCs.Reference Teshale and Knowledge18,Reference Linkov, Trepacova, Kureckova and Pai41 In contrast, a study in Poland showed that 66.2% of drivers stated that they would check if the RTC scenes were safe before administering first aid.Reference Karyś, Rębak, Karyś and Ksroka47 Furthermore,Reference Olugbenga-Bello, Sunday, Nicks, Olawale and Adefisoye34 most participants believed that bystanders should initiate first aid. In the current research, this behavior is due to the lack of knowledge of first aid provision despite their willingness to help as good Samaritans. Besides, a first aid kit is unavailable to mitigate the fear of infections; therefore, they prefer to handle the cases with professionals.
Practice
In this study, most participants showed poor self-reported practice in managing difficult breathing. The same gap was observed in over one-half of the participants concerning stopping bleeding and handling leg fractures. In other similar studies, poor practice was also observed in three-quarters of motorcyclistsReference Makota and Kibusi22 and among drivers.Reference Olumide and Owoaje49,Reference Sangowawa and Owoaje50 In contrast, Olugbenga-BelloReference Olugbenga-Bello, Sunday, Nicks, Olawale and Adefisoye34 revealed that at least 51.5% of participants knew the correct way to stop bleeding, while fracture stabilization was correctly applied by 88.5% of participants. As mentioned earlier, the current study’s poor self-reported practice is linked to insufficient baseline knowledge.
Association between Sociodemographic Characteristics and Other Factors of Participants and their KAP Level
In this study, previous first-aid training, the year they attended first-aid training, education level, being a member of the Red Cross, and awareness of emergency call numbers for police were significantly associated with the knowledge level. Similar results were found in Benin among motorcyclists and in Tanzania among traffic officers.Reference Lukumay, Ndile and Outwater15,Reference Glèlè-Ahanhanzo, Kpade, Kpozèhouen, Levêque and Ouendo35 In this study, the participants’ exposure to courses related to first aid should improve their knowledge of this matter.
Concerning attitudes, previous first-aid training and the year the participants attended first-aid training were statistically associated with their attitudes. These results align with a study by Linkov in which participants who had previously participated in first aid sessions reported feeling more confident and capable of administering first aid than non-participants.Reference Linkov, Trepacova, Kureckova and Pai41 The explanation may be linked to the first aid knowledge, which shapes the attitudes and actions regarding aiding victims.
Moreover, there was a significant association between participants’ self-reported practice and age, previous first-aid training, education level, and being a member of the Red Cross. This association may be related to the exposure to first aid knowledge and skills from training, which contribute to good practice.
Predictors of Knowledge Attitudes and Self-Reported Practice
In this study, previous first-aid training and knowing emergency call number for the police predict good knowledge. The same results were found in Ethiopia, whereby drivers with previous first-aid training and adequate knowledge were five-times more likely to provide first aid than those without,Reference Teshale and Knowledge18 as well as in the following studies: Ssewante,Reference Ssewante, Wekha and Namusoke28 Glèlè-Ahanhanzo,Reference Glèlè-Ahanhanzo, Kpade, Kpozèhouen, Levêque and Ouendo35 and Saqer.Reference Saqer48 On the other hand, studies have shown that some people underwent first-aid training, but there is still a discrepancy between being trained and showing adequate knowledge and appropriate related practice.Reference Duut, Okyere, Zakariah, Donkor and Mock19,Reference Hancock, Delaney and Eisner26,Reference Heard, Pearce and Rogers40,Reference Olumide and Owoaje49 This study’s prediction is likely linked to previous knowledge from the last first-aid training.
Moreover, the awareness of the emergency contact number for police also significantly increased the odds of having good knowledge. The findings were parallel to the studies from Uganda and Poland.Reference Ssewante, Wekha and Namusoke28,Reference Karyś, Rębak, Karyś and Ksroka47 In contrast, less than one-quarter of the participants knew the emergency contact number for the police in Benin.Reference Glèlè-Ahanhanzo, Kpade, Kpozèhouen, Levêque and Ouendo35 Road users need to be aware of the emergency contact number in the case of an accident so that rescue personnel can be dispatched quickly.
Previous first-aid training was a significant predictor of positive attitudes. These findings are consistent with the study conducted by Linkov, where attending first-aid training previously was also associated with confidence and a feeling of ability to provide first aid compared with the participants who didn’t participate.Reference Linkov, Trepacova, Kureckova and Pai41 The reason is that the participants gain knowledge during first-aid training, influencing their attitudes and behaviors toward the victims’ assistance.
Furthermore, age, previous first-aid training, education level, and the number of victims cared for were significant predictors of the self-reported first aid practice. The same results mirrored the surveys conducted by TeshaleReference Teshale and Knowledge18 and Ssewante,Reference Ssewante, Wekha and Namusoke28 whereby individuals who had first-aid training and a high level of education were more likely to practice first aid than those who did not. In this study, this prediction is linked to the factors previously found in first aid knowledge, as the last one is considered a prerequisite for the excellent practice of first aid.
Limitations
The study findings cannot be generalized because the participants were all recruited from an urban area, and their KAP level would differ from motorcyclists from the rural area of Rwanda, given the disparity in education status. In addition, the self-reported practice was elicited among the participants due to the complexity of reaching the scene of RTCs on time and the ethical issues of applying what they know to an actual victim.
Conclusion
The study reported low knowledge and self-reported practice of first aid provision among commercial motorcyclists in Kigali City. This gap creates barriers to attitudes that can lead to the avoidance of bystanders and passers-by in providing first aid. Furthermore, first-aid training and education level were mainly predictors and associated with good knowledge, positive attitudes, and good practice. Globally, considering these findings, first-aid training is needed.
Therefore, it is recommended that community members learn first-aid training. In addition, motor vehicle drivers primarily involved in or near RTC scenes to transport victims to health facilities should receive mandatory first-aid training before getting a driving license. This is a step toward leveraging prehospital care to improve RTC outcomes, especially in LMICs with a shortage of emergency services. Lastly, further studies on motorcyclists are needed as most published papers focus on drivers even though motorcyclists are among the most vulnerable RTC victims.
Acknowledgments
The authors acknowledge the Organization for Women in Science for the Developing World (OWSD; Trieste, Italy) for supporting this study.
Conflicts of interest
The authors declare none.
Author Contributions
CUM contributed to the conception, design, and manuscript writing. KLS designed and supervised the entire study process. RAM performed statistical and data analysis. KKCM reviewed the manuscript critically. TT contributed to statistical analysis and manuscript editing.
