First-aid practices and pre-hospital care in paediatric snakebites

Abstract

Background

Snakebites pose a serious health risk to children in Sri Lanka, particularly in rural areas. Inappropriate first-aid measures and delayed hospital access contribute to adverse outcomes. This study examined caregiver first-aid practices and factors linked to harmful responses.

Methods

A descriptive cross-sectional mixed-methods study was conducted across four tertiary hospitals in Sri Lanka. Quantitative data were collected from 364 pediatric snakebite cases through structured caregiver interviews. First-aid practices were categorized as safe or potentially harmful. Logistic regression identified predictors of harmful practices. Additionally, 54 qualitative interviews explored caregiver beliefs and behaviours.

Results

While 264 (73.4%) caregivers washed the wound with soap and water and 222 (61.1%) reassured the child. Harmful practices were frequently observed: 97 (26.7%) applied tourniquets, 27 (7.4%) used herbal or home remedies such as lime or mashed onions, 9 (2.5%) attempted to suck out venom, 5 (1.5%) performed religious rituals before hospital care, 2 (0.5%) made incisions to drain blood, and 1 (0.2%) applied Condy’s crystals. Harmful practices were significantly associated with low maternal education (AOR 1.94; p < 0.001), low paternal education (AOR 2.26; p < 0.001), low socioeconomic status (AOR 3.67; p < 0.001), and cultural beliefs regarding traditional cures (AOR 2.64; p < 0.001). Remote healthcare access was a borderline significant factor (AOR 1.28; p = 0.05). Prior training in snakebite first aid was protective (AOR 0.21; p < 0.001). Qualitative findings revealed coexistence of traditional and biomedical practices and frequent transport-related delays.

Conclusion

Despite moderate awareness of recommended first aid, harmful practices persist in paediatric snakebite care in Sri Lanka. Targeted, culturally sensitive education and improved rural emergency transport services are essential to reduce delays and prevent complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-025-05975-0.

Background

Snakebite envenomation remains a significant public health concern in tropical and subtropical regions, disproportionately affecting rural and resource-limited communities [1]. In Sri Lanka, snakebites are a well-recognized cause of hospital admissions, with children representing a particularly vulnerable demographic due to their outdoor exposure and smaller body mass, which increases the risk of severe envenomation [2]. Despite the establishment of national treatment guidelines and availability of antivenom in tertiary hospitals, morbidity and mortality related to snakebites persist—often due to delays in care and suboptimal first-aid measures administered prior to hospital arrival [3].

Effective first aid plays a critical role in mitigating the effects of envenomation and improving clinical outcomes [4]. The World Health Organization (WHO) recommends a set of evidence-based first-aid practices, including immobilizing the affected limb and early transport to a healthcare facility [5]. However, across many parts of Sri Lanka, first-aid responses to snakebites are frequently influenced by traditional beliefs, cultural practices, and misinformation, which may result in potentially harmful interventions such as the use of tourniquets, application of herbal remedies, or attempts to suck out venom [6].

While prior studies have documented adult snakebite cases and hospital-based outcomes, there remains a paucity of evidence specifically addressing paediatric snakebite cases, particularly with regard to pre-hospital care and first-aid practices. Furthermore, there is limited understanding of the sociocultural and systemic factors that shape caregiver behaviour during these critical moments following a bite [7]. Recognizing this gap, the present study employed a mixed-methods approach to explore first-aid practices and pre-hospital care among paediatric snakebite victims in Sri Lanka.

This study aimed to (1) describe the patterns of first-aid measures used by caregivers following snakebites in children, (2) identify socio-demographic and systemic determinants associated with potentially harmful practices, and (3) explore caregivers’ perspectives, beliefs, and barriers to evidence-based care through qualitative inquiry.

Methods

Study design and settings

A multi-center, descriptive cross-sectional study was conducted across four major referral hospitals in Sri Lanka: Colombo North Teaching Hospital, Kurunegala Teaching Hospital, Polonnaruwa Teaching Hospital, and Anuradhapura Teaching Hospital. These hospitals were selected due to their high caseloads of paediatric snakebite cases, as well as their representation of both urban and rural settings. The hospitals serve as key tertiary care centers in regions with a high incidence of snakebites (Fig. 1), particularly in rural areas where encounters with snakes are more frequent due to agricultural activities and environmental factors.

Fig. 1.

Distribution of study settings (DGH; District General Hospital, NCTH; North Colombo Teaching Hospital, TH; Teaching Hospital)

Study population

The study included children aged 0 to 17 years who presented to the selected hospitals after sustaining a snakebite. Both snakebite cases involving medically significant snakes (Fig. 2) and those involving non-significant or less medically important snakes were considered [8]. The identification of the snake was confirmed through visual recognition, either by caregiver bringing the snake to the hospital (alive or dead) or by providing a clear photograph of the snake. The identification of the snake at the study settings was performed by the attending paediatrician and clinical team based either on direct identification or other available visual evidence. When species recognition was uncertain, the national snake identification service was consulted for expert input to ensure accurate snake recognition. Exclusion criteria included cases where the snake species could not be identified—either due to unknown bite circumstances or inability to recognize the snake—and instances where informed consent was not obtained.

Fig. 2.

Medically important snakes in Sri Lanka; A. Common/Indian krait (Bungarus caeruleus), B. Russell’s viper (Daboia russelii), C. Common/Indian cobra (Naja naja), D. Hump-nosed pit vipers (Hypnale spp.), E. Saw-scaled viper (Echis carinatus), F. Ceylon/Sri Lankan krait (Bungarus ceylonicus) and G. Green pit viper (Peltopelor trigonocephalus). (By curtesy of the Expert Committee on Snake Bites, Sri Lanka Medical Association)

Sample size and sampling procedure

A total of 364 children were enrolled in the study, representing all consecutive paediatric snakebite admissions meeting inclusion criteria over a three-year period. Participants were recruited from four major referral hospitals in Sri Lanka: Anuradhapura Teaching Hospital (n = 134), Polonnaruwa District General Hospital (n = 92), Kurunegala Teaching Hospital (n = 78), and Colombo North Teaching Hospital, Ragama (n = 60). The study team included three investigators and trained research assistants, who were responsible for data collection across the sites. These assistants, fluent in local languages, collected data under direct supervision and followed standardized protocols to ensure consistency across hospitals. There was no sampling frame, and all eligible cases were consecutively included. The study assessed first-aid practices across both medically significant and non-significant snakebites.

Data collection

Data were gathered through prospective interviews with caregivers. A structured, pre-tested data collection form was used to collect information on demographic characteristics (e.g., age, sex, household income, parental education level, residential location), snakebite details, and first-aid practices. First-aid practices were categorized into safe practices (e.g., washing the wound gently with water, immobilizing the affected limb) and potentially harmful practices (e.g., applying tourniquets, using home remedies like lime or herbal mixtures). Interviews were conducted by trained research assistants fluent in Sinhala or Tamil and were completed within 24 h of the child's hospital admission to minimize recall bias.

Study variables

First-aid practices were categorized as either safe or potentially harmful based on based on the Sri Lanka Medical Association (SLMA) Snakebite First Aid Guidelines and expert consensus. Safe practices included washing the bite site with water, immobilizing the affected limb, reassuring and calming the child, and removing constrictive items such as bangles or cords. Potentially harmful practices included the application of tourniquets, attempting to suck out venom, making incisions or draining blood, and the use of traditional remedies such as lime, mashed onions, herbal mixtures, or Condy’s crystals. Performing religious rituals or devotions prior to seeking medical care was also classified as harmful as they may delay administration of antivenom.

Several independent variables were defined for analysis based on caregiver characteristics and contextual factors. Previous experience of giving first aid to a snakebite victim was defined as any prior occasion in which the caregiver had personally administered first-aid measures to an individual following a snakebite. Parental education level was categorized according to the highest completed level of formal schooling. “No formal education” referred to parents with no school attendance. “Primary education” included completion of grades 1–5. “Secondary education (incomplete)” referred to those who attended grades 6–11 without completing the national GCE (General Certificate in Education) Ordinary Level examination. “Secondary education (complete)” denoted successful completion of GCE O/L. “Advanced Level education” corresponded to completion of GCE A/L. “Tertiary education” referred to any post-Advanced Level education, including university or vocational training. Low maternal and paternal education were each defined for the study as not having completed secondary education. Socioeconomic status was categorized as low if the household’s monthly income was reported to be less than LKR 50,000 consistent with national poverty thresholds and prior health studies conducted in Sri Lanka [9, 10]. Remote healthcare access was defined as a travel time exceeding 30 min to reach a health facility capable of managing snakebites. This threshold was based on previous Sri Lankan and South Asian studies that associate delayed access beyond this time with increased morbidity in snakebite victims [6, 11]. Difficulties with emergency transportation referred to caregiver-reported delays or challenges in securing timely transport, including unavailability of ambulances or reliance on informal vehicles such as three-wheelers. Belief in cultural practices for cure was defined as reliance on or trust in traditional or ritual-based interventions—including herbal applications, religious offerings, or consulting traditional healers—prior to or alongside medical treatment. Previous training in snakebite-related first aid was defined as having received formal or informal instruction on appropriate first-aid practices, either through community programs, health worker outreach, or school-based education initiatives.

Qualitative study

A total of 54 parents participated in the qualitative component of the study, which was designed to explore their experiences and perspectives on first-aid practices following paediatric snakebites. The interviews were guided by a semi-structured thematic framework that ensured consistency while allowing flexibility to probe context-specific issues. The framework was developed based on existing literature, expert consultation, and preliminary field observations. It categorized questions under six thematic domains: (1) knowledge and beliefs about snakes and envenomation, (2) first-aid measures taken at the time of the bite, (3) sources of information or training on snakebite care, (4) cultural or traditional influences on decision-making, (5) barriers to accessing hospital care, and (6) reflections on the overall experience.

Participants were purposively selected to ensure relevance and diversity of perspectives. Particular emphasis was placed on recruiting parents whose children had been exposed to potentially inappropriate or harmful first-aid practices, allowing for an in-depth exploration of real-life responses and decision-making. This sampling strategy enabled the research team to examine a wide range of beliefs and behaviours surrounding snakebite response. Efforts were made to ensure heterogeneity within the sample, capturing a wide range of perspectives from parents of diverse educational, socioeconomic, and rural backgrounds. However, it is important to acknowledge that purposive sampling introduced selection bias, as participants were not randomly selected and may not represent the full spectrum of caregiver experiences in the wider population. The final sample size was guided by the principle of data saturation—the interviews continued until no new significant themes emerged from the discussions. Interviews were conducted in participants’ native language and were audio-recorded for transcription and analysis. The duration of each interview ranged from 10–15 min. Saturation was achieved after conducting 40 parent interviews.

Data analysis

Quantitative data were entered into a password-protected electronic database and analysed using IBM SPSS Statistics version 26.0. Descriptive statistics were used to summarize demographic characteristics, first-aid practices, and other study variables. The chi-square test was employed to assess the association between first-aid practices and various demographic factors, including parental education level and socioeconomic status. Multiple logistic regression was used to identify factors independently associated with harmful first-aid practices. The outcome variable was binary (harmful practice: yes/no), and predictors included parental education, socioeconomic status, healthcare access, cultural beliefs, transport difficulties, prior experience, and training. Adjusted odds ratios (AORs) with 95% confidence intervals were calculated to control for confounding.

Thematic analysis was used to examine the qualitative data, following the approach outlined by Braun and Clarke (2006) [12]. This process involved a two-stage analytic strategy. Initially, descriptive (first-order) codes were developed to identify recurring patterns across the data. Subsequently, a second-order thematic analysis was undertaken to interpret and contextualize these patterns, enabling the exploration of deeper meanings, assumptions, and sociocultural influences embedded within participants’ narratives. To ensure the rigor and trustworthiness of the analysis, we maintained a systematic and transparent coding process, and engaged in regular reflexive discussions throughout the analytic phase. Consistency in interpretation was strengthened by ongoing documentation of analytic decisions.

Ethical considerations

Ethical approval was obtained from the Ethics Review Committee of the Postgraduate Institute of Medicine, University of Colombo. Written informed consent was obtained from the parents or guardians of all participating children, and assent was sought from children aged 12 years and older. All data were anonymized, and confidentiality was strictly maintained throughout the study.

Results

Among 364 children presented with snakebites, the majority of snakebite victims were children aged 8–12 years, with a mean estimated age group of approximately 11.2 years (SD ± 3.5). Males were more frequently affected (64.3%), and most children came from rural households (87.9%). Over half of the families earned between LKR 30,000–50,000 (52.1%), reflecting a predominantly low- to middle-income population. Parental education was generally limited, with 40.4% not completing secondary school (Table 1).

Table 1.

Demographic characteristics of children with snakebites (n = 364)

Demographic characteristics	Variable	n (%)
Age	up to 4 years	28 (7.7%)
	> 4–8 years	59 (16.2%)
	> 8–12 years	143 (39.3%)
	> 12–17 years	134 (36.8%)
Sex	Male	234 (64.3%)
	Female	130 (35.7%)
Household income (LKR)	< 30,000	32 (8.8%)
	30, 001–50,000	195 (52.1%)
	50,001–100, 000	110 (29.4%)
	> 100,000	27 (7.2%)
Highest education level in a parent	No Formal Education	5 (1.6%)
	Primary Education	19 (6.1%)
	Secondary Education (Incomplete)	123 (33.8%)
	Secondary Education (Complete)	100 (31.8%)
	Advanced Level Education	91 (29.0%)
	Tertiary Education	26 (8.3%)
Type of residential location	Rural	320 (87.9%)
	Urban	44 (12.1%)

Among the 364 pediatric snakebite cases, 181 (49.7%) involved medically significant species, with the Hump-nosed viper (60.8%) being the most common culprit. Other serious envenomations were due to Russell’s viper (14.9%), kraits, and cobras. The remaining 183 bites (50.3%) were from non-venomous or mildly venomous snakes, such as rat snakes (32.2%) and water snakes (30.6%) (Table 2).

Table 2.

Pattern of snakes implicated in paediatric envenomations

Highest medically important snakebites (n = 181)		Less medically important and nonvenomous snakebites (n = 183)
Hump-nosed viper	110 (60.8%)	Rat snakes	59 (32.2%)
Russell’s viper	27 (14.9%)	Water snakes	56 (30.6%)
Common krait	24 (13.3%)	Vine snakes	19 (10.4%)
Cobra	12 (6.6%)	Cat snakes	16 (8.7%)
Saw-scaled viper bites	5 (2.8%),	Trinket snakes	16 (8.7%)
Ceylon krait	2 (1.2%)	Wolf snakes	10 (5.5%)
Green pit viper	1 (0.6%	Other	7 (3.8%)

First-aid responses among caregivers showed a mix of safe and potentially harmful practices. Whilst 223 caregivers (61.1%) reassured the child, nearly half (49.7%) immobilized the affected limb. The majority of caregivers washed the wound with soap and water 267 (73.4%). Harmful practices were still evident: 26.7% applied tourniquets, and 7.4% used home remedies such lime, mashed onions or herbal mixtures. A small number resorted to practices such as sucking out venom (2.5%) or performing religious rituals before seeking care (1.5%) (Table 3).

Table 3.

Patterns of first-aids practiced by the caregivers

First-aid practice
Reassure and calm the patient	223 (61.1%)
Keep the affected area still	181 (49.7%)
Wash the wound with soap and water	267 (73.5%)
Remove any rings, bangles, anklets, cords or clothing, which could cause constriction	2 (0.5%)
Apply a tourniquet above the snakebite site	97 (26.7%)
Suck out the venom	9 (2.5%)
Apply Condy’s crystals on the wound	1 (0.2%)
Apply onions/lime/coconut milk or herbal mixtures on wound	27 (7.4%)
Make an incision and drain out the blood	2 (0.5%)
Conduct any religious practices, devotions for the child's recovery before taking the child to the hospital	5 (1.5%)

The analysis revealed several key factors linked to harmful first-aid practices for snakebites. Previous training in snakebite first-aid was strongly associated with not practicing any unsafe first-aids (AOR 0.21, p = 0.00). Low maternal and paternal education (AOR 1.94, p = 0.00 and AOR 2.26, p = 0.00) and socio-economic status (AOR 3.67, p = 0.00) were strongly associated with the practice of harmful practices (Table 4).

Table 4.

Determinants of potentially harmful first-aid practices

		Univariate analysis		Multivariate analysis
	Potential determinants	OR (CI)	p value	AOR(CI)	p value
1	Previous experience of giving first-aid to a snakebite victim	1.71(1.08–2.28)	0.02	1.64(1.22–2.40)	0.04
2	Low maternal education	2.13(1.62–3.09)	0.00	1.94(1.38–2.92)	0.00
4	Remote health care facilities	1.76(1.38–2.26)	0.01	1.28(1.05–1.82)	0.05
5	Beliefs regarding cultural practices for cure	2.82(2.07–3.97)	0.00	2.64(1.03–3.56)	0.00
6	Difficulties with emergency transportation	1.48(1.12–2.04)	0.03	1.22(0.92–1.69)	0.12
7	Low socio-economic status	4.12(2.44–5.52)	0.00	3.67(2.26–5.13)	0.00
8	Low paternal education	2.21(1.14–2.59)	0.00	2.26(1.32–2.42)	0.00
9	Previous training snakebite related first-aids	0.24(0.11–0.33)	0.00	0.21(0.14–0.28)	0.00

Parents’ perspectives of pre-hospital first-aid practices

This analysis reveals a nuanced landscape of pre-hospital care, where many caregivers exhibit commendable knowledge and initiative—particularly in washing wounds and seeking hospital care. Yet, these actions are often interwoven with traditional, cultural, and spiritual practices that can both help and hinder outcomes. A majority of caregivers demonstrated familiarity with appropriate first-aid responses, particularly washing the bite site with soap and water—reported by 73.5% of participants. This practice aligns with WHO-recommended snakebite first-aid and suggests that public health messaging may have permeated community knowledge to some extent.

“I used soap and water right away. Then we went to the temple and tied a pandura for the gods before heading to the hospital.” (Parent 24, Anuradhapura).

This quote illustrates a dual-response logic: even when biomedical first aid is initiated correctly, it is often paired with spiritual practices, reflecting a worldview in which divine protection is essential for healing. Such responses indicate a complementary belief system in which ritual reinforces recovery.

Even in cases with limited access to resources, caregivers acted promptly within their means: “There was no soap nearby, so we just used water to clean the bite.” (Parent 104, Polonnaruwa) This demonstrates a baseline awareness that cleaning the wound is critical, even under pressure. In a high-stress, time-sensitive situation, such a response reflects decisive action and an intuitive understanding of first-aid priorities. It also illustrates that even without complete resources, caregivers are capable of initiating meaningful steps toward care, highlighting the value of reinforcing simple, feasible actions through community education.

Traditional practices layered onto first-aid

While many initiated appropriate care, several caregivers also applied traditional or home remedies such as lime, herbal mixtures, or tight cloth bindings. These actions are often based on intergenerational knowledge or community beliefs, and while well-intentioned, they may be harmful or delay definitive treatment. “We washed with soap, then applied lime and tied a cloth tightly above the wound.” (Parent 189, Polonnaruwa).

“Soap and water first, but then we brought the child to a local traditional healer on the way to the hospital, and he applied a herbal mixture over the bite site.” (Parent 202, Polonnaruwa).

This reflects a layered model of care, in which traditional remedies are not seen as alternatives to biomedical treatment, but rather as complementary steps driven by habit, cultural belief, or a desire to provide every possible form of help. Such practices highlight the deep-rooted cultural frameworks that shape caregiving decisions in moments of crisis. They underscore the importance of culturally attuned health education—approaches that do not dismiss these traditions, but instead build trust and gently guide communities toward safe, evidence-based practices without undermining their values.

In some cases, harmful traditional practices such as tying tight bands above the bite site continue to be commonly used:

“We tied a tight cloth just above the bite — that’s what we’ve always been told stops the venom from spreading.” (Parent 231, Anuradhapura).

“I put some lime and mashed onions on the area. That’s how our elders treated bites in the past.” (Parent 144, Polonnaruwa).

These accounts reveal a deep and enduring reliance on inherited knowledge, passed down through generations and deeply embedded in local norms. Despite ongoing public health efforts to discourage practices such as tourniquet use, many caregivers still turn to these methods in moments of urgency. This suggests that the authority to act in medical crises often stems not from clinical guidelines, but from familial wisdom and cultural memory. When such traditions conflict with medical advice, it is not ignorance but trust in ancestral ways that shapes action—highlighting the need for community engagement strategies that honour these beliefs while gently steering them toward safer, evidence-based care.

Emergency transport: gaps, delays, and local solutions

Getting to the hospital quickly is crucial for effective snakebite management. However, caregivers frequently described logistical challenges in accessing timely care, including limited ambulance availability and the need to rely on motorbikes and three-wheelers.

“There was no ambulance, so we put him on the bike and went as fast as we could.” (Parent 98, Polonnaruwa) “We called for an ambulance, but it was taking too long. The three-wheeler was faster.” (Parent 176, Polonnaruwa).

These statements point to a practical prioritization of speed over formality. Even when caregivers knew that hospitals were the destination, they faced barriers in reaching them, leading to workarounds that could compromise safety or delay arrival.

In some instances, proximity and familiarity shaped the route to care: “We went to a traditional healer to suck out the venom — it was closer than the hospital, and we thought it would be quicker.” (Parent 218, Anuradhapura).

These parents’ perspectives capture the complex interplay between geography, belief, and urgency. Trust in local healers, coupled with poor access to formal care, may lead caregivers to initiate care in settings that lack medical efficacy. These decisions are not solely about belief—they are structurally shaped by the realities of rural life. Rather than framing these practices as “right” or “wrong,” public health interventions should aim to engage with cultural logic. Programs must go beyond didactic teaching to build trust, clarify misconceptions, and respectfully challenge harmful traditions such as tight tourniquets or delays in care-seeking due to religious rituals. At the same time, the overwhelming reliance on informal transport highlights the need to invest in rural ambulance networks, community paramedic training, and faster referral systems. Strengthening these infrastructures can bridge the gap between cultural practices and clinical care, ensuring that correct first aid is not undone by systemic delays.

Discussion

This mixed-methods study provides an overview of first-aid practices and pre-hospital care in paediatric snakebite cases across four major hospitals in Sri Lanka. Our findings reveal that while a majority of caregivers practiced at least one recommended first-aid measure—such as washing the wound or calming the child—a significant proportion also engaged in potentially harmful practices, including applying tourniquets (26.7%), using traditional remedies (7.4%), and attempting to suck out venom (2.5%). These unsafe responses were strongly associated with low parental education, lower household income, cultural beliefs in traditional cures, and poor healthcare accessibility. Importantly, prior training in snakebite first aid was a protective factor. The qualitative findings further revealed that caregiver decisions were shaped by a combination of emotional urgency, inherited practices, and logistical barriers, with many parents layering biomedical care alongside cultural or spiritual responses. Together, these results highlight the urgent need for context-sensitive interventions that address both informational gaps and systemic constraints. These findings are consistent with prior research across South and Southeast Asia, which has documented the persistence of inappropriate first-aid responses in rural communities despite increased awareness campaigns and improvements in healthcare infrastructure [11, 13–15].

Globally, inappropriate pre-hospital practices remain a major contributor to snakebite-related morbidity and mortality [16]. Studies from India, Nepal, and Bangladesh report similar patterns of tourniquet use, wound incision, and the application of traditional substances, often driven by cultural beliefs and lack of access to timely medical care [17–19]. Our findings echo these trends, with 27.3% of caregivers in our cohort reporting the use of tourniquets—despite national and WHO guidelines advising against it.

The association between low parental education and harmful first-aid practices has been consistently highlighted in the literature [20]. Our study reinforces this link, underscoring how limited educational attainment restricts access to accurate health information and promotes reliance on traditional knowledge systems. Socioeconomic status also played a significant role, with lower-income households more likely to resort to traditional or home-based remedies, a trend noted in studies from Sub-Saharan Africa and Southeast Asia [21–23].

Qualitative data from this study illuminated the “layered” nature of care-seeking behaviour, where traditional and biomedical approaches are often used concurrently. Caregivers frequently turned to ritualistic treatments not solely out of superstition, but also due to cultural norms and social pressures. This aligns with observations from studies in Malawi [24], Nigeria [25] and Myanmar [11], where caregivers pursued multiple avenues of care to satisfy both biomedical urgency and traditional expectations.

Beyond cultural beliefs or limited knowledge, many caregiver actions appeared to be shaped by emotional urgency, situational uncertainty, and the need to make rapid decisions in high-stakes moments. Several parents described acting out of fear, guilt, or the desire to “do something immediately,” even if that action did not align with biomedical recommendations. This psychological dimension of care-seeking—where decision-making is driven as much by emotional logic as by cultural tradition—has been underappreciated in prior snakebite literature. In such scenarios, the use of home remedies or tight cloth bindings was not always a deliberate rejection of medical care but a coping response to uncertainty, especially when access to hospitals was delayed or ambiguous [26, 27]. Furthermore, the influence of social expectations—such as needing to follow advice from elders or perform religious rituals to avoid blame—played a significant role in shaping first-aid practices. These findings highlight the complex interplay between individual agency, social norms, and perceived responsibility, particularly in environments where biomedical resources are scarce or slow to reach. Interventions that seek to improve snakebite outcomes must therefore address not just knowledge deficits, but also emotional, social, and contextual pressures that shape caregiver behaviour in real time [28].

Emergency transportation and geographic accessibility emerged as key structural barriers. Although Sri Lanka’s free public health system ensures hospital care, caregivers often reported delays in ambulance arrival in remote areas or relied on private transport due to urgency. Similar constraints have been documented in rural India and South East Asia, where lack of reliable transport infrastructure was linked to delayed antivenom administration and worsened outcomes [29, 30]. This points to the urgent need to strengthen pre-hospital systems, including the training of community-level responders and improving ambulance networks in remote areas.

Encouragingly, our data also highlight a foundational awareness among many caregivers regarding the need for hospital referral and basic first-aid principles such as wound washing and limb immobilization. This provides a platform upon which public health interventions can build. Educational programs that are community-specific, culturally sensitive, and delivered through trusted local channels—such as public health midwives, school teachers, and traditional healers—are likely to be more impactful [31]. Similar community-based interventions in Nepal and Kenya have shown promise in improving snakebite-related knowledge and reducing harmful practices [32, 33].

Based on the findings of this study, we recommend the development and implementation of targeted, evidence-based public health interventions to improve first-aid responses to paediatric snakebites in Sri Lanka. Community-level capacity-building initiatives—such as training programs for caregivers, schoolteachers, and public health midwives—should focus on disseminating accurate, WHO-aligned first-aid guidelines while addressing common harmful practices such as tourniquet use and traditional remedies. Public awareness campaigns should be culturally sensitive and delivered through trusted local networks, including religious leaders and community elders, to effectively challenge misconceptions without alienating caregivers. Additionally, strengthening rural emergency transport systems and incorporating snakebite education into school curricula can play a vital role in reducing pre-hospital delays and improving outcomes. These recommendations aim to translate research findings into actionable strategies that enhance community preparedness and reduce the morbidity associated with paediatric snakebites.

Several limitations must be acknowledged. First, the study relied on caregiver recall of first-aid practices, which may be subject to recall bias or social desirability bias. Second, the study focused on patients who reached tertiary hospitals; thus, the findings may not capture practices among those who never presented to formal care facilities. Additionally, while thematic saturation was achieved in the qualitative component, the findings may not be generalizable beyond the regions studied.

Conclusion

This study reveals a nuanced picture of first-aid and pre-hospital care practices in paediatric snakebite cases in Sri Lanka. While many caregivers demonstrated awareness of safe first-aid practices, harmful traditional methods and systemic barriers continue to challenge effective care. Low parental education, socio-economic disadvantage, and cultural beliefs were key determinants of harmful practices. Importantly, caregivers often layered traditional responses with biomedical ones, underscoring the need for culturally attuned educational interventions.

Authors’ contributions

K.D. designed the study, carried out data collection following appropriate methodology, analysed data, and wrote the manuscript. N.S., P.B. carried out data collection. K.D., N.S. and P.B. read and approved the final manuscript.

Funding

No funding was received.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to sensitive nature of data but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Ethics Review Committee of the Postgraduate Institute of Medicine, University of Colombo (ERC/PGIM/2024/029). Written informed consent was obtained from parents of all children prior to recruitment of children in the study. The study procedures were done in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.