|Year : 2020 | Volume
| Issue : 1 | Page : 10-21
Development and implementation of a first responder program in rural Haiti: The involved citizen project
Annelies De Wulf1, Adam R Aluisio2, Briana L Hecht3, Christina Bloem4
1 Division of International Emergency Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
2 Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
3 School of Public Health, SUNY Downstate Medical Center, Brooklyn, USA
4 Department of Emergency Medicine, Division of International Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, USA
|Date of Submission||08-Feb-2019|
|Date of Acceptance||01-Jul-2019|
|Date of Web Publication||27-Mar-2020|
Dr. Annelies De Wulf
Louisiana State University Section of Emergency Medicine, 2000 Canal Street, D and T, Building Suite 2720, New Orleans, LA 70117
Source of Support: None, Conflict of Interest: None
Background: Northeast Haiti lacks comprehensive prehospital emergency medical services (EMS). Most patients requiring medical care are transported via motorcycle taxis or on foot. This project evaluates the feasibility and impact of a train-the-trainer program designed to improve capacity of community members to provide initial emergency care through contextually adapted first aid skills.
Methods: This observational cohort study identified a geographically representative cohort of leaders to serve as trainers. These leaders were trained to teach a locally oriented first aid curriculum designed in concert with Haitian partners. This curriculum emphasized use of readily available materials in provision of care and was aimed at locally prevalent conditions. An accompanying Haitian Creole course manual with embedded teaching guides was developed. These trainers in turn trained local community members, with recruitment focused on local drivers who can ultimately act as de facto first responders in the region.
Results: Thirty-five individuals were recruited, of which 51.4% achieved criteria to become independent trainers. Within 6 months of the initial training course, 44.8% of trainers reported using the skills they had been taught. The trainers taught 271 community members first aid skills within the study period. Of these, 33.1% of participants reached in follow-up surveys reported providing first aid in their communities and 19.8% had transported persons in need of emergency care to a healthcare facility since completion of the course.
Conclusions: This train-the-trainer model is an effective method for strengthening the capacity of communities to care for medical emergencies in the Northeast region of Haiti. This program may be important to building a future formal EMS system in the region and may be applicable to similar resource-limited settings.
The following core competencies are addressed in this article: Patient Care, Medical Knowledge, System-Based Practice.
Keywords: Community response, emergency care, first aid, Haiti
|How to cite this article:|
De Wulf A, Aluisio AR, Hecht BL, Bloem C. Development and implementation of a first responder program in rural Haiti: The involved citizen project. Int J Acad Med 2020;6:10-21
|How to cite this URL:|
De Wulf A, Aluisio AR, Hecht BL, Bloem C. Development and implementation of a first responder program in rural Haiti: The involved citizen project. Int J Acad Med [serial online] 2020 [cited 2020 May 25];6:10-21. Available from: http://www.ijam-web.org/text.asp?2020/6/1/10/281459
| Introduction|| |
Low- and middle-income countries (LMICs) represent 90% of the global burden of deaths due to injuries, with road traffic accidents as one of the primary causes. Both injuries as well as exacerbations of chronic and communicable diseases require rapid intervention and access to emergency care.
Development of prehospital emergency medical services (EMS) in LMICs is challenging. The cost of ambulances, equipment, and upkeep is significant. Poor infrastructure of roads can often render them impassable to emergency transport vehicles. Furthermore, training of personnel can be costly, and finding the political will to invest in already strained healthcare systems is difficult. These resource-limited environments call for novel approaches that expand the existing infrastructure, create immediate impact, and serve as a bridge to the slow pace of formal system change. Tiska et al. showed that truck drivers, who were serving as the de facto emergency transport mechanism in Ghana, when trained in first aid, were able to rapidly implement prehospital care where none previously existed. This exemplifies task shifting, a strategy where tasks are transferred from higher-skilled, but scarce, providers to more readily available human resources, thus filling a void in care.
The northeast region of Haiti is economically strained, with poor transit infrastructure, an under-resourced healthcare system and no formal prehospital care. Most patients reach the hospital by for-hire motorcycle taxis, and community clinics have limited diagnostic and treatment capabilities. Local hospitals receive 25% traumatic injuries and 75% medical emergencies, highlighting the need for adequate emergency care. With an approach of civic engagement and task shifting, however, human capacity can be built and self-efficacy reinforced. Previous work, identified engaged community members through which interventions could be readily implemented, with appropriate training. Long-standing relationships with local stakeholders set up the necessary foundation for an intervention that has the potential to integrate with future formal emergency medical systems.
This project evaluates the feasibility and impact of a locally developed training program designed to improve capacity of community members to respond and provide initial emergency care through contextually adapted first aid response skills. The project also pilots a framework to allow for continuation of an independent, skilled, Haitian trainer workforce for training community members in first response.
| Methods|| |
Study design and setting
This observational cohort study took place in the northeast region of Haiti, an under-resourced area of the country with geographically dispersed healthcare assets (see map). The program sought to distribute trainings throughout the region, so as to reach more remote areas with limited healthcare access. The project received local ethics review and approval from the departmental ministry of public health (Ministère de la Santè Publique et de la Population, MSPP) [Appendix 1].
Preintervention engagement and selection of participants
Recruitment for the train-the-trainer program began in 2012–2013, when local partners and key informants identified healthcare stakeholders in the region. These individuals were asked about local healthcare needs and to nominate community leaders for a train-the-trainer first responder course. Efforts were made to recruit throughout the northeast for comprehensive geographic coverage. Expecting a 50% rate of attrition, a goal of up to 40 recruits was set.
First aid training-curriculum development
The curriculum was developed by emergency medicine specialists with previous clinical experience in Haiti in concert with locally practicing physicians using iterative-modified Delphi techniques. The intent was to develop an adapted course relevant to local emergencies, utilizing locally available materials (e.g., clothing, lumber, and plastic bags), rather than difficult to obtain medical equipment. The course was designed in two parts: part one was a train-the-trainer program, aiming to teach trainers the medical knowledge and instructional skills to teach the curriculum and part two was a community-based training program focused on teaching interested community members these skills. Within the training cohorts, there was an emphasis on recruitment of drivers of motorcycle taxis, to leverage access to transport to health facilities when indicated.
First aid training-tools development
Distinct manuals were developed for both project phases: the initial trainer development phase and the community responder scale-up phase. Each manual was developed, piloted, and revised to maximize comprehension and efficacy in a 1-day course. Manuals were developed in English, professionally translated into Haitian Creole, then subsequently member checked by Haitians in the region for comprehension and errors. The manuals use photographs and illustrative diagrams to account for varying levels of literacy. The student manual was developed as a learning tool for participants during first responder training courses and to use as a reference after course completion. The trainer manual has additional instruction and tips for the trainers when teaching community-based courses.
Standardized trainer evaluation tools were developed in English and Haitian Creole to assess content knowledge acquisition, as well as instructional abilities [Appendices 2 and 3].
Part 1: Train-the-trainer course
The didactic sessions took place in April 2014 and were taught by local physicians in Haitian Creole or emergency medicine specialists from the United States in English with translation [Figure 1]. The course was a single day, taught at a local school centrally located in the northeast region. The first responder curriculum was taught with an emphasis on practical skills of safe patient transportation, splinting, etc. A subsequent single day training in October 2014 focused on instructional skills and ensuring understanding of the content material. As needed, review sessions were held by project leaders.
Part 2: Community trainings
From January through December 2015, four community trainings were taught by the Haitian trainers, which were observed by project staff [Figure 2]. The trainers recruited local community members, with an emphasis on drivers. The courses were taught in towns throughout the region [Figure 3]. The venue was arranged by the trainers themselves and included churches, schools, and meeting halls. They taught in groups of 4–7 trainers at a time and received logistical support by project leaders, who also observed the trainings and provided debriefing feedback to ensure trainer competency in teaching and fidelity in application of the course material. Community trainings again focused on practicing hands-on skills of emergency first response. Project leaders also evaluated the trainers on their knowledge and teaching ability. When trainers achieved passing criteria based on the knowledge checklist and teacher competencies evaluation, they were graduated to independent trainers. They then became eligible for per diem payments for teaching subsequent courses and no longer required assistance by study staff to teach a course. Throughout this time, local administrative and expert support were available to trainers to facilitate trainings and review materials as needed. Furthermore, the project personnel continued to spot check courses for appropriate evolution and material accuracy.
| Monitoring and Evaluation|| |
Part 1: Train-the-trainer course
Following the first didactic session, course participants were asked if they wanted to become a trainer as a measure of acceptability of the course and queried as to their overall sentiments on the course. Follow-up surveys were performed via telephone approximately 6 months and 12 months after the initial didactic session to ask if participants had used any of the first aid skills. A standardized course evaluation was also administered per telephone to ask trainers about the effectiveness of the course 6 months following the didactic session and 3 months following the teaching workshop.
Part 2: Community trainings
Community training participants were given pre- and post-tests to evaluate knowledge uptake. During the 6–12 months after the first two community trainings, participants were contacted via telephone and surveyed using a structured data collection tool administered by trained study personnel to minimize responder bias. The follow-up assessment collected data on community-based first aid provision, skill usage, and whether community responders had transported (or assisted with transport of) anyone to the hospital since undergoing training. There was no data collection directly from recipients/patients of the community members trained in first aid skills.
Data analysis was performed using STATA version 15.0 (StataCorp; College Station, USA). Descriptive analyses were undertaken for the first aid trainers. Variables were described using frequencies with percentages or means with associated standard deviations. Significant differences in first aid provision between those working in the transportation sector and those who did not were evaluated using Pearson χ2 or Fisher's exact tests with odds ratios (ORs) and associated 95% confidence intervals calculated to provide magnitudes of associations.
The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were followed in the reporting of the research.
| Results|| |
Part 1: Train-the-trainers course
Thirty-five trainers were recruited locally in the northeast to complete the trainer course. Of the 35 recruited trainers, 28 (80.0%) returned for the second didactic trainer course. Of the original recruits, 51.4% (18/35) became independent trainers after completing the didactic curriculum, being observed hosting community trainings and passing the predetermined criteria.
[Table 1] describes the demographic characteristics of the graduated trainers. The majority were female (61.1%) with an average age of 43.5 years. More than half (61.1%) of trainers had occupations with some training in the healthcare field. The specific occupations of the trainers are detailed in [Table 2]. The trainers' areas of residence were distributed across the northeast region of Haiti, including the towns of Acul Samedi, Ferrier, Grand Bassin, Terrier Rouge, and Derac [Figure 3].
Of the initial 35 trainers recruited when surveyed after the first didactic course, 100% stated they would like to complete the training to become independent trainers immediately after the course and again at 6-month follow up. Feedback obtained from prospective trainers about the course at 6-month follow-up was largely positive (e.g., “great”, “helpful”). At 12-month follow-up, feedback obtained demonstrated that trainers largely found the course useful and effective, while participants were not completely confident in their mastery of the material [Table 3]. Follow-up surveys conducted at 6 months and 12 months after the initial train-the-trainer course revealed that 44.8% (13/29) and 36.4% (8/22), respectively, of trainers surveyed reported use of the first aid skills learned in the course [Table 3]. Among trainers who reported using their skills, the specific skills used were splinting, bleeding control, ABCs, scene safety, and self-protection.
Part 2: Community trainings
At follow-up assessment of trainer community implementation (December 2015), the majority (66.7%) of trainers had taught first aid courses. More than half of the trainers (55.6%) taught two courses, two trainers (11.1%) taught one course since graduation. The average number of participants per course taught has been 21 (±2) [Table 1].
During the reported evaluation period, 271 community members were trained in first aid by the trainers. Of these, 62.4% were male and the average age was 30.6 years. Drivers in the public transportation sector accounted for approximately a quarter of participants (24.4%). Prior first aid training was reported by 12.3% of participants [Table 4]. The participants in the first aid courses resided primarily in the cities where trainings were conducted, or in nearby cities in the northeast of Haiti (see map).
Follow-up telephone surveys finished approximately 1.5 years after the first training (9 trainers and 121 community responders reached) revealed that 33.1% of community responder course participants reached reported providing first aid in their communities since completing the course. Nearly, 19.8% had transported persons in need of emergency care to a healthcare facility [Table 5]. Drivers were more likely to have reported providing community-based first aid compared to nondrivers (46.3% vs. 26.9%, P = 0.024), with an OR of 2.34 (95% CI: 1.09–5.05, P = 0.025). Drivers were also more likely to have transported a person in need of higher level of treatment to a healthcare facility compared to nondrivers (26.8% vs. 12.6%, P = 0.047), with an OR of 2.53 (95% CI: 0.98-6.58, P = 0.048).
| Discussion|| |
In this program, community leaders became trainers in first response care, thus developing capacity in locales with limited existing healthcare assets. Subsequently, the program allowed trainers to direct the first responder curriculum to individuals most likely to provide care and transportation to health facilities: professional drivers. This was achieved using a setting-appropriate framework and as such was less costly than a purely external training program.
The train-the-trainer method has been cited as an effective approach to disseminating a culturally appropriate emergency care curriculum and to developing a locally sustainable training infrastructure., We found that this model built local capacity in emergency care skills and laid groundwork for future self-sustaining educational programs. Specifically, over 250 community responders were trained and short-term follow-up demonstrated provision of attained skills. This highlights how these individuals can be effectively leveraged to address gaps in prehospital care in areas lacking formalized EMS. Given our limited follow-up period, future longer term evaluations would be beneficial to inform subsequent programs' impact and sustainability.
Local adaptation is central to this program. First aid training relying on expensive equipment and outside materials have limited reproducibility, scalability, and sustainability in resource-constrained settings. By using locally available materials (sticks, sheets, and bags), this project sought to increase community members' ability to manage medical emergencies long term without ongoing external inputs. Furthermore, local partner involvement allowed the curriculum to be tailored appropriately and to address community concerns.
Many of those who were trained provided first aid care following their course. While some of the trainers were healthcare providers or teachers, none were previous experts in first aid, so they essentially task shifted to become emergency care responders. This is congruent with and adds to the literature's data showing that laypersons can become confident first responders in settings lacking a formal EMS system.,, Through meeting criteria to graduate as independent teachers, the trainers proved that they could assimilate, retain, and effectively teach the skills they learned.
Task shifting, however, is not without challenges. As one study evaluating surgeons' perspectives on task shifting pointed out, there is the potential for individuals with less training to provide substandard care. Quality control measures, care standards, and guidelines, as well as appropriate oversight must be put into place in order to ensure safety., As the described program was implemented, ongoing assessments found that trainers and participants had varying levels of literacy, foundational health knowledge, and comfort with learning and teaching the material. Accordingly, the curriculum underwent several iterative revisions during implementation, and multiple review sessions were offered to the trainers. Direct supervision from project staff was provided until the trainers demonstrated through predetermined criteria that they could do trainings independently, a process that extended beyond the initially planned timeframe due to quality concerns. This is in agreement with a recommendation in Tanzania to perform ongoing training and to establish limits on task shifting for a positive, sustainable impact in healthcare delivery. Community-based training programs likely benefit from ongoing refreshers, member checking, assessments of successes and failures, and willingness to address these in a dynamic way.
Community engagement remains a challenge in any long-term sustainable program. The time and dedication required for the trainers to adequately learn and teach was significant. There was no guarantee of remuneration for this work, and only a token salary was paid to graduated trainers. For participants in the community trainings, taking time off from work to attend a whole day training was a reported challenge. Given the lack of financial incentivization, participation was likely driven by a desire to improve health-care access and feel empowered to manage health emergencies. Local partners helped maintain engagement through teaching, referring appropriate individuals to the program, and consistently underscoring a focus on local leadership. Similar models in Iran found that to maintain motivation, utilizing existing community assets and focusing on community empowerment were crucial. However, as noted in a study examining Ugandan community health workers, it is important to evaluate ongoing motivational influences and to provide continued support.
Previous studies have found that external aid has had unintended negative consequences for Haiti's health system, including siphoning resources and patients away from government-run hospitals., This implemented program sought from conception to coordinate with existing healthcare assets and partnered with MSPP throughout the process. This locally driven approach ensured applicability and uptake of the program.
There are several limitations to this study. First, data collection was challenged with language and literacy barriers and ultimately was done by interview. As interviews were not anonymous, this may have led to reporting bias. Follow-up and retention were also difficult. Some trainers who began the program ultimately stopped participating, citing being too busy with other jobs. Trainers and participants both were often difficult to contact, due to changes in cell phone numbers and migration. This lowered trainer retention and may have skewed reported skills usage. In addition, although data were collected on care delivery from the trained participants, there was no data directly collected from patient recipients in the communities, which precludes the ability to assess programmatic translational impacts on objective health outcomes. Future work to evaluate objective patient level endpoints would be beneficial to inform implementation efficacy.
The program curriculum was specifically designed to address the health needs of the population in Northeast Haiti. As such, generalizability is not certain. However, given the ubiquity of common emergency care needs, it is feasible that it could be applicable elsewhere. Furthermore, the building blocks of developing a locally adapted curriculum relying heavily on local partner input, developing informal emergency response personnel from existing community assets, and utilizing the train-the-trainer model likely could be applied in other resource-limited settings with success.
As there is currently not a system in place for dispatching or identifying those who have been trained beyond local word of mouth, the use of first responders is not being maximized. These present opportunities for developing more comprehensive community-based emergency care activation mechanisms and response systems. Future programmatic phases should also establish a more formalized collaboration between first responders and the developing formal EMS.
| Conclusion|| |
The involved citizen project shows that the train-the-trainer model can be an effective method to strengthen capacity of remote and/or medically underserved populations to care for medical emergencies in the northeast region of Haiti. This program was successfully implemented through the use of a locally adapted curriculum responsive to the needs of community members, low cost and easily sourced materials, and employment of task shifting. This model may be important to building a future formal EMS system in the region and may be applicable to similar resource-limited settings.
We would like to thank Dr. Bendson Louima and Dr. Roudy Durand for their invaluable advice, inspiration, and friendship. Also, we thank Jacques-Mary Saintus for his logistical assistance, guidance, and enthusiastic teaching. We thank Drs. Emily and Jonel Daphnis of Melanin Photography and Ms. Bethany Bandera of Bandera Photography for their photographic donations and assistance in the development of the instruction manual. Importantly, this project would not have been possible without the dedication and perseverance of the trainers and participants of the involved citizen project.
Financial support and sponsorship
This project was funded by SUNY Downstate Medical Center Department of Emergency Medicine and by EMEDEX International. The authors of this study have affiliations with one or both of the above institutions.
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
The project received local ethics review and approval from the departmental ministry of public health (Ministère de la Santè Publique et de la Population, MSPP). This project was conducted in accordance with the ethical standards guidelines provided by the CPCSEA and World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Humans.
| Appendix|| |
Appendix 1: Letter of Approval MSPP Haiti Involved Citizen Project
Involved Citizen Project
EMEDEX International seeks to improve access to emergency medical care for the people of Northeast Haiti. In collaboration with local partners, we seek to respond to the medical needs of the community through the improvement of local resources. By training first responders, the Involved Citizen Project will enable these communities to provide basic emergency care, which has not been previously available.
This community participatory project is locally adapted to be able to provide first response and emergency care in a limited resource setting. It will train laypeople in first aid through a “train the trainers” model, where local people will be trained to teach a locally adapted first responder course. These trainers will then, in turn, train other community members in first aid. EMEDEX expects that this new healthcare knowledge will permit the improvement of quality of life of the population and that the interventions by the community members now trained will, as a result, decrease avoidable deaths in the region. The trained persons will then, in the future, be able to interact with a formal ambulance system, especially in areas that are not accessible by ambulance, where the presence of qualified personnel will be of value. The trained responders will be evaluated with pre and post tests and also with a followup survey 6 months after the course. The information collected will be anonymous and confidential. We ask for the support of the MSPP (Ministry of Health) for this project.
Dr. Christina Bloem
Dr. Adam Aluisio
Dr. Annelies De Wulf
Appendix 2: Checklist of Trainer Specific Critical Performance Steps
The Involved Citizen Project Training Manual
Checklist of Trainer Specific Critical Performance Steps
Criteria for passing is ≥ 50% for each section.
Explain to students that it is important to assess a scene so that you do not become sick or injured while trying to help someone else
Provide specific examples of possible dangers or
hazards (chemical spill, unstable buildings, downed power lines, and autos on the road)
Emphasize the importance of continuous reassessment of a scene for rescuer safety
Personal Protection and Hygiene
Describe standard precautions to decrease the spread of disease (wash hands, avoid contact with blood/body fluids, and wear personal protective equipment)
Emphasize that hand washing is the most important step to prevent the spread of infection
Name devices that can be used as personal protective equipment (gloves, masks, eye protection, and gowns)
Assess the need for help by asking, “Are you ok?”
Describe each component of the ABCDs:
A- open airway
B- look listen and feel
C- look for signs of inadequate circulation (cool, sweating skin) and control bleeding
D- Check mental status, identify spinal injuries
Management of a Choking Person
Describe the difference between a partially blocked and completely blocked airway (in a partially blocked airway, the person can still breathe, cough, etc)
Stress the importance of intervening quickly in the case of completely blocked airways
Demonstrate/explain hand placement positions for abdominal thrusts and back blows in conscious adults
Demonstrate/explain chest compressions for unconscious adults
Demonstrate/explain back blows and chest thrusts for all choking infants less than one year old (conscious and unconscious are the same)
Control of Bleeding
Demonstrate techniques for mild and severe bleeding control (bandage, direct pressure)
Emphasize that continued direct manual pressure is the best way to control bleeding
Describe when tourniquets are indicated and stress why they should be a last resort (risk of limb ischemia/death)
Wound Care and Burn Care
Emphasize the importance of washing with water and stress that washing with clean water only is adequate
Explain which burns require advanced care (e.g., location on hands or feet, genitals or face, large size, full-thickness or deep wounds, signs of infection, neurovascular compromise, compromised ABCDs)
Fracture Management and Splinting
Explain the goals of splint placement (reduce pain, prevent major bleeding, and prevent further injury)
Describe the principles of splinting (immobilize the bones or joints above and below the injury)
Effectively explain the techniques of splint and sling application
Head and Spinal Injuries
Discuss signs of head and spinal injuries (e.g., confusion, weakness, neck, or back pain)
Describe what neutral alignment is
Explain the importance of neutral alignment in spinal protection (to prevent further injury, paralysis)
Carrying and Transporting the Injured Person
Emphasize which carrying techniques are safe with a spinal injury (logrolling and the use of a stretcher) and without a spinal injury (other carries)
Discuss ways to create a stretcher and transport patients using readily available materials (rice bags, rugs, boards, etc)
Explain the principle of logrolling (to keep the spine straight to prevent further spinal injury)
Instructor Candidate Name ____________________
Master Instructor Name _______________________
Master Instructor Signature ____________________
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]