Enhancing first-aid self-efficacy: A randomized trial comparing three interactive educational ınterventions

Abstract

BACKGROUND:

Effective first-aid education is a critical public health strategy to reduce the burden on emergency services. This study aimed to evaluate and compare the effectiveness of three interactive first-aid training modalities (case-, video-, and drama-based) on university students’ first-aid self-efficacy.

MATERIALS AND METHODS:

A three-arm randomized controlled trial with a pretest–post-test design was conducted. The study included 93 university students, randomly assigned to three intervention groups (n = 31 each). The intervention groups received six core first-aid topics delivered through case-, video-, or drama-based methods, while the control group received unstructured education. Data were collected using the “First Aid Self-Efficacy Scale.” Statistical analysis was performed using analysis of covariance to compare post-test scores while controlling for baseline differences.

RESULTS:

More than 95% of the participants were unmarried, and more than 50% in each study group were female. Post-test mean scale scores were highest in the case-based group (194.16 ± 25.17), followed by the video-based (190.61 ± 24.08), drama-based (168.22 ± 54.37), and unstructured groups (162.29 ± 45.19). Baseline sociodemographic assessments revealed a statistically significant difference in gender distribution across groups (p = 0.008). However, after adjusting for these baseline scores, the study results showed no statistically significant differences between the three interactive training groups in total first-aid self-efficacy or its subdimensions at post-test (p > 0.050). While all groups demonstrated a longitudinal improvement in self-efficacy scores from preintervention to postintervention, no single interactive method demonstrated statistical superiority over the others.

CONCLUSıON:

Interactive first-aid training, regardless of the specific modality, is effective in enhancing students’ self-efficacy. These findings suggest that educators can flexibly employ a range of interactive strategies to achieve comparable outcomes in prehospital emergency care training. Interactive first-aid training meets essential health policy benchmarks for emergency preparedness, offering educators flexible, effective, and interchangeable modalities to enhance public self-efficacy.

Introduction

First aid is an indispensable issue for human life, regardless of place, time, or cause, and it is a nonmedicated intervention that prevents the deterioration of the situation, both physically and psychologically, for the person whose health is in danger.[1] First aid is most needed in the case of an accident, and early intervention within the first hour increases the survival rate. In the literature, the first hour is called “gold hour,” and the first 10 minutes are more critical than the hour.[2] One study found that timely and adequate care is vital because in about half of traumas, death occurs within the first hour. Especially in traumas, the proper intervention before emergency aid saves lives. It improves the quality of emergency aid.[3] Situations that require first-aid application can happen to anyone at any time, but they are encountered more frequently, especially in schools.[1,4]

Many studies have been conducted specifically on first-aid issues among university students. A study was conducted on university students. It recommends that first-aid training is helpful for university students and the child development department, but that the service should continue work-life training. Also, the students’ knowledge of foreign body aspiration in the trachea is high.[5] In another study, university students’ attitudes toward epilepsy were examined, and their level of knowledge was found to be very high. However, their level of recognition of epilepsy symptoms was found to be low.[6] In school environments, especially in times of crisis, students are expected to be involved in the process. Students need to be trained to respond to crises through a program. Counsellors should collaborate with health professionals to carry out these processes. The absence of guidance services in university settings can put students at a disadvantage. In this context, university students should be better equipped in first aid. This situation is especially critical at state universities with large student populations.[7]

Student attitude, motivation, and self-efficacy are important factors that affect self-efficacy. A study conducted with university students in the nursing department determined that these factors directly affected basic life support practices. The same study suggested that future studies should examine different factors.[8] The concept of self-efficacy was also addressed in our study. Although there are many definitions of self-efficacy, it generally refers to how individuals perceive their capacity to perform necessary activities. If an individual’s self-efficacy is low, their stress levels and job performance are low. They cannot easily give up or finalize the process in the face of crises; even if they do, they lack the necessary beliefs.[9] A study was conducted with students in the Department of Child Development, and it was found that their knowledge of tracheal foreign body aspiration, which plays an important role in first aid, was high. It was determined that the students’ self-efficacy levels were low. It was recommended that the frequency of first-aid training be increased to enhance self-efficacy. First aid is a competence that all students need in the short and long term. Therefore, it was emphasized that training should continue throughout life, with more frequent and comprehensive sessions.[5]

Demonstration and enabling students to apply their knowledge are among the leading interactive education methods. This study demonstrates the technique and the application configuration that students will use. Many studies have been conducted to improve the quality of first-aid training and make it more effective. One study suggests that measuring participants’ needs, interest levels, and expectations regarding first aid before first-aid training can increase the training’s effectiveness.[10] When planning first-aid training, the characteristics and needs of the people receiving training are essential. Using a tailored, hands-on teaching method, the study found that first-aid training for children with special needs was forgotten after 2 months.[11] Another study investigated the effectiveness of first-aid training techniques. In the training, the number of course hours students had in formal education was associated with their fatigue. Students with more hours of school lessons had a lower desire for first-aid training. It was determined that they had difficulty concentrating. The same study found that delivering first-aid training by experienced instructors positively affected educational outcomes.[12] Health workers need to organize training and create guidelines for first aid to increase knowledge. In a study on burns, it was found that individuals’ knowledge was limited. It was emphasized that there is a need for guides on the subject.[13]

In a randomized controlled trial comparing three first-aid training methods, the interactive method produced the best results.[14] Continuing this study, the current study will be at the forefront of determining which of the three interactive methods we have chosen will be more effective. Thus, it aims to create evidence for use in first-aid training. The primary objective of this study was to evaluate and compare the effectiveness of three distinct interactive first-aid training modalities (case-, video-, and drama-based) on university students’ first-aid self-efficacy levels.

Hypotheses: The study tested the following null hypotheses (H₀)

H₀1: Case-based first-aid training has no statistically significant effect on students’ first-aid self-efficacy.

H₀2: Video-based structured first-aid training has no statistically significant effect on students’ first-aid self-efficacy.

H₀3: Drama-based structured first-aid training has no statistically significant effect on students’ first-aid self-efficacy.

Materials and Methods

Study design and setting

The study was a three-arm, randomized, controlled, pretest − post-test experiment to determine the effect of three interactive first-aid training methods on students’ first-aid self-efficacy [Figure 1]. Participants were allocated to the four study arms using clustered randomization, a method specifically chosen to balance key demographic variables, and the study was single-blind (assessor-blind).

Figure 1.

Conceptual framework of interactive first-aid interventions

The research was conducted within the scope of the first-aid course during the spring semester of the 2022–2023 academic year. The study training was carried out between April and June 2023. The research was conducted in three different departments at Tokat Gaziosmanpasa University. The first department is the Nursing at the Faculty of Health Sciences. The second department is the Midwifery at the Faculty of Health Sciences. The third department is Child Care and Youth Services/Child Development at Tokat Vocational School of Health Services. The fourth department is the Penal Execution and Security Services at the Vocational School of Justice.

Study participants and sampling

The participants are undergraduate and bachelor’s degree students in three different departments at Tokat Gaziosmanpasa University. In the study, a power analysis was conducted using G × Power 3.1.9.7 to determine the minimum number of students needed to participate in preapplication first-aid training. The sample size was calculated using the repeated-measures analysis of covariance (ANCOVA). With an effect size of f = 0.39, α err prob = 0.05, number of groups = 4, and number of measures = 2, the minimum number of participants to be included in the sample was determined to be 24. Impact value is determined by evidence from impact value studies on first aid and self-efficacy.[15,16] Since there might be dropouts, the research sample was selected with 31 students in each group. In total, 11 participants declined participation, 18 withdrew during the study period, and 10 provided incomplete questionnaire data. These cases were excluded from the final analysis.

Participants were assigned to one of the four groups (three intervention groups and one control group) using a clustered randomization method. A computer-generated random number sequence was utilized to ensure unbiased allocation. To ensure internal validity, a single-masked (assessor-blind) design was adopted. Although the instructors were aware of the training modalities, the individual responsible for collecting the pre- and post-test data was blinded to the group assignments. This blinding of the outcome assessor was maintained throughout data entry and analysis to minimize potential bias and ensure the objectivity of the findings. Also, this measure was taken to prevent assessor bias and ensure the objectivity of the self-efficacy measurements [Figure 2].

Figure 2.

Consort diagram

There are 165 second-year students enrolled in the first department; 82 fourth-year students enrolled in the second department; 126 students enrolled in the third department (64 morning shift students and 62 afternoon shift students); and 32 second-year students enrolled in the fourth unit. The research sample comprised 31 students per department. The clustered randomization technique was used to assign the students to the first, second and third departments. The complete count sampling technique was used to assign the students to the fourth department. The criteria for inclusion in the study were not exceeding the course absenteeism limit and volunteering to participate. Health vocational high school graduates were excluded from the study.

Data collection tools and techniques

The researcher-developed Information Form and the First Aid Self-Efficacy Scale were used to collect the research data. Information Form consisting of demographic questions such as gender, age, high school attended, department studied, and a total of 10 questions related to first aid.

The First Aid Self-Efficacy Scale (FASES), developed by Gulmez-Dag and Capa-Aydin,[17] was used to assess participants’ self-efficacy. The scale consists of 25 items across two subdimensions: Self-Efficacy for Life Support (SLS, 17 items) and Self-Efficacy for Basic First Aid (SBFA, 8 items), rated on a 9-point Likert-type scale (1: Insufficient to 9: Very sufficient). Regarding validity, the original two-factor structure was confirmed in this study through expert consultation to ensure content validity for the target student population. For reliability, the original study reported Cronbach’s alpha values of 0.96 and 0.91.[17] In the present study, the scale demonstrated high internal consistency, with a total Cronbach’s alpha of 0.969, and the subdimensions yielded 0.958 for SLS and 0.916 for SBFA, confirming the instrument’s reliability in this sample.

Data collection tools (pretest) were applied to all students before the intervention. There were three interactive intervention groups in the study. Three interactive methods were compared with a control group that received unstructured first-aid training. In short, interactive and unstructured training techniques were compared.

To evaluate practical skill proficiency, an Objective Structured Clinical Examination (OSCE) was administered in a laboratory setting to all participants after completing the training modules. The OSCE consisted of standardized stations where students performed specific first-aid procedures (AED, CPR, bleeding control) under the observation of independent evaluators using structured checklists. Success was defined as achieving a minimum score of 70 on the skill performance criteria. The OSCE results indicated that all intervention groups, as well as the control group, successfully demonstrated the required first-aid competencies.

The interventions for the intervention groups are detailed in Table 1. The applications to be made within the scope of the first-aid course are six: Basic Life Support, Automatic external defibrillator use, Airway obstruction, Bleeding, Fractures, dislocations, and sprains, and patient/injured transportation techniques. All intervention groups were introduced to the six basic first-aid practices. One topic was covered each week. Each intervention was conducted for one class hour per week. Each practice session lasted 45 minutes on average, and sessions were held once a week.

Table 1.

Overview of interactive first-aid training content and modalities

Arms		Learning modality		Pedagogical basis		First-aid training content, aim
Arm 1/Intervention 1		Case-based interactive learning		Cognitive integration and problem-based reasoning		The case-based group analyzed three specific clinical scenarios in each session, focusing on decision-making steps. Six structured first-aid cases were developed to address core competencies sequentially over six weeks. Each session transitioned from instructor-led theoretical demonstrations to guided, case-based practice. This approach required learners to apply demonstrated procedures within realistic scenarios, thereby fostering cognitive integration, problem-based reasoning, and active engagement in contextual decision-making.
Arm 2/Intervention 2		Video-based observational learning		Modelling and visual reinforcement		The video-based group watched standardized 10-minute training videos sourced. Video materials aligned with the six core competencies were compiled, primarily utilising anonymised educational resources from the Turkish Ministry of Health. Following instructor demonstrations in theoretical sessions, students viewed and replicated the procedures during practical sessions. Consistent instructor support was provided to maintain focus and ensure accurate imitation, thereby facilitating observational learning and procedural reinforcement within a standardized instructional framework.
Arm 3/Intervention 3		Drama-based experiential learning		Experiential engagement and embodied learning		The drama group followed a structured role-playing script where students took turns as rescuers and victims. Students were assigned to small groups for each of the six core competencies and provided with standardized drama scripts. Following instructor demonstrations during theoretical sessions, learners enacted first-aid scenarios through structured role-play. To maximize immersion, the learning environment was augmented with simulated sensory cues (e.g., accident sounds), thereby promoting emotional engagement, role adherence, and embodied learning through experiential enactment.
Control Group		Unstructured practice-based learning		Skill repetition without a guided learning design		No preprepared instructional materials or structured learning scenarios were provided to this group. Following instructor demonstrations in theoretical sessions, students practised the six first-aid procedures independently during practical sessions. While procedural oversight ensured task completion, the learning process occurred without explicit pedagogical structuring or targeted learning mechanisms, serving as a baseline for comparison with the interactive modalities. The unstructured education group received a traditional training session based on the national standardized first-aid curriculum. The education was delivered using the official presentation slides developed and approved by the Republic of Turkiye Ministry of Health.[51] These slides cover core first-aid protocols and are publicly available through the Ministry’s General Directorate of Emergency Health Services website. This ensured that the control group received the baseline educational standard required at the national level, albeit without the additional pedagogical structures (e.g., case studies, drama) applied to the experimental groups.

Due to the laboratory conditions, not all students were able to complete the intervention at the same time. Practices are done in groups. Classes were designed for randomly selected students and nonselected students. The technique was applied to the study participants, and the others received unstructured training at a different class time than the standard control group [Table 1]. The implementations were done in different class hours. After the sessions (2^nd test), data collection tools were reapplied to all participants. The detailed lesson plans, sample clinical cases, drama scripts, and video sources used in the training sessions are provided as Supplementary Materials [Appendix A] to ensure the reproducibility of the study.

Ethical consideration

All procedures performed in this study were in accordance with the ethical standards of Tokat Gaziosmanpasa University. University and the 1964 Helsinki Declaration and its later amendments, or with comparable ethical standards. Permission to use the scale in the research was obtained from the developers. Necessary permissions were obtained from Tokat Gaziosmanpasa University, Social and Human Sciences Research Ethics Committee (date: 25.04.2023; approval no. 01.37). Institutional permission was obtained from Tokat Gaziosmanpasa University, and written informed consent was obtained from the participants who agreed to participate in the study.

Statistical analysis method

The study data were analyzed using SPSS 25.0 (Statistical Package for the Social Sciences). Skewness and kurtosis tests, along with Z values, were examined to determine whether the data were normally distributed. All skewness and kurtosis values examined in this study were less than 2.5. Percentages and averages were used to analyze the data. The Chi-square test was used for categorical comparisons. The data analysis procedures, including the rigorous testing of the null hypotheses (H01, H02, and H03), were detailed to evaluate the comparative effectiveness of the instructional modalities. Statistical analysis was performed using ANCOVA to compare post-test scores while controlling for baseline differences. Games-Howell post hoc test was used. In all statistical procedures used in the research, the significance level will be set at 0.05.

Results

Regarding participants’ marital status, more than 95% were single, indicating a highly homogeneous sample in terms of social and family responsibilities. Regarding gender distribution, more than 50% of participants in each study group were female, ensuring a consistent demographic profile across groups. The OSCE results indicated that all intervention groups, as well as the control group, successfully demonstrated the required first-aid competencies. There is a difference between groups regarding gender (P = 0.008). They are similar in other respects (P > 0.05). Students in all groups stated that they had previously encountered foreign body (n = 2), epilepsy (n = 1), bleeding (n = 2), fainting (n = 1), fracture (n = 1), and burn (n = 1) [Table 2].

Table 2.

Comparison of participant demographics, first-aid information across groups

First-aid and sociodemographic characteristics		Case-based intervention 1 (n=31)		Video-based intervention 2 (n=31)		Drama-based intervention 3 (n=31)		Nonstructured Control group (n=31)		χ2 P
		n (%)		n (%)		n (%)		n (%)
Gender
Women     Men		19 (61.3) 12 (38.7)		30 (96.8) 1 (3.2)		25 (80.6) 6 (19.4)		23 (74.2) 8 (25.8)		11.884 0.008
Marital status
Married     Unmarried		0 (0.0) 31 (100.0)		0 (0.0) 31 (100.0)		1 (3.2) 30 (96.8)		1 (3.2) 30 (96.8)		0.566 2.033
Receiving a first-aid course
Yes     No		2 (6.5) 29 (93.5)		3 (9.7) 28 (90.3)		6 (19.4) 25 (80.6)		1 (3.2) 30 (96.8)		5.167 0.160
First-aid knowledge level
Adequate     Partially sufficient     Inadequate		4 (12.9) 24 (77.4) 3 (9.7)		8 (25.8) 20 (64.5) 3 (9.7)		4 (12.9) 19 (61.2) 8 (25.8)		1 (3.2) 24 (77.4) 6 (18.4)		10.378 0.110
First-aid application status (Did they give you first aid?)
Yes     No		5 (16.1) 26 (83.9)		5 (16.1) 26 (83.9)		7 (22.6) 24 (77.4)		8 (25.8) 23 (74.2)		1.353 0.717
First-aid situation (Did you apply first aid?)
Yes     No		3 (9.7) 28 (90.3)		4 (12.9) 27 (87.1)		3 (9.7) 28 (90.3)		2 (6.5) 29 (93.5)		0.738 0.864

χ²: Chi-square test value; P: Statistical significance level (P<0.05 significance)

Those who had first-aid experience stated that they had provided first aid to their grandmothers (n = 1), mothers (n = 1), fathers (n = 1), a wounded person they did not know (n = 7), and nephews (n = 1). Two students had practised basic life support before. The number of students who said they had practised first aid entirely was 11, and 2 stated that they had done it incompletely [Table 2].

The post-test mean scores of the groups were ranked from highest to lowest as follows: the case-based training group exhibited the highest self-efficacy scores (194.16 ± 25.17), followed by the video-based training group (190.61 ± 24.08), the drama-based training group (168.22 ± 54.37), and finally, the unstructured (traditional) education group (162.29 ± 45.19). Post-test outcomes were analyzed using ANCOVA, with the corresponding pretest scores entered as covariates. This approach allowed the comparison of adjusted post-test means while accounting for baseline self-efficacy levels [Table 3].

Table 3.

Comparison of participants’ mean scores of first-aid self-efficacy and its subscales

Scale and subscales		Case-based intervention 1 (n=31)		Video-based intervention 2 (n=31)		Drama-based intervention 3 (n=31)		Nonstructured Control group (n=31)		(F)P η²
		x̄±SD		x̄±SD		x̄±SD		x̄±SD
First-aid Self-Efficacy Scale
Pretest		190.35±23.96		185.09±27.11		170.29±47.66		161.29±41.18		(1.12) 0.350 0.050
Post-test		194,16±25,17		190,61±24,08		168,22±54,37		162,29±45,19		(0.04) 0.830 0.002
Self-Efficacy for Life Support (SLS) subscale
Pretest		128.16±16.84		124.22±20.02		113.41±33.26		105.29±28.40		(1.28) 0.290 0.060
Post-test		130.90±17.67		128.16±17.65		112.16±37.38		106.93±30.64		(0.060) 0.810 0.003
Self-Efficacy for Basic First Aid (SBFA) subscale
Pretest		62.19±7.76		60.87±7.64		56.87±15.30		56.00±14.65		(1.94) 0.430 0.040
Post-test		63.25±7.99		62.45±7.22		56.06±17.68		55.35±15.92		(0.01) 0.910 0.001

F: ANCOVA F-test value; P: Statistical significance level (P<0.05 significance); η²: Partial eta squared (effect size)

After controlling for baseline scores, ANCOVA revealed no statistically significant differences in adjusted post-test total First Aid Self-Efficacy scores among the groups, F (3, 59) = 0.04, P = 0.830, partial η² = 0.002. The small effect size indicates that the type of educational intervention had a negligible impact on overall first-aid self-efficacy, even after accounting for baseline differences.

Similarly, ANCOVA results for the Life Support Self-Efficacy subscale showed no significant group effect after adjusting for pretest scores, F (3, 59) = 0.06, P = 0.810, partial η² = 0.003. The effect size was tiny, suggesting that improvements in life support self-efficacy were comparable across all groups, regardless of the intervention method.

For the Basic First Aid Self-Efficacy subscale, ANCOVA also demonstrated no statistically significant differences between groups after controlling for baseline values, F (3, 59) = 0.01, P = 0.910, partial η² = 0.001. This finding indicates that gains in basic first-aid self-efficacy were uniform across intervention and control groups, with no evidence of differential effectiveness.

Discussion

This study evaluated the effects of three interactive first-aid training methods on university students’ first-aid knowledge levels. The demographic characteristics of the study participants and the information they provided about their first-aid experiences are essential.

The gender distribution of participants and information about the emergencies they had encountered helped us better understand the study results. There were (61.3%) 19 girls and (38.7%) 12 boys in intervention group I, (96.8%) 30 girls and (3.2%) 1 boy in intervention group II, (80.6%) 25 girls and (19.4%) 6 boys in intervention group III, and (74.2%) 23 girls and (25.8%) 8 boys in the control group. This shows significant differences in gender distribution between the groups. In line with gender examinations in similar literature, recent evidence indicates that while first-aid knowledge increases significantly across educational levels, no substantial gender disparities were observed. This suggests that the attained level of education is a more dominant predictor of knowledge acquisition than gender.[18] 86.0% of the students’ gender was female in the study comparing the effectiveness of the lecture method and mobile learning method in Basic Life Support education,[19] and 82.9% of the students’ gender was female in another study examining the effect of two different evaluation methods on the Basic Life Support learning process.[20] In the study comparing distance education’s synchronous and asynchronous processes, which has become the basis of the education process during the pandemic in Basic Life Support education, 213 were girls.[21] After the literature review, it was determined that the gender distributions of this study were similar. In the study, male students are fewer than female students, which can be explained by the fact that students in these departments are predominantly female, as professions in the health field are perceived as gender-specific.

Students’ prior emergency and first-aid experiences are also noteworthy. The fact that the majority of the participants stated that they had previously encountered emergencies such as foreign body ingestion, epilepsy, bleeding, fainting, fractures, burns, etc., indicates that the likelihood of encountering emergencies in general is high. In addition, the fact that some students reported practising first aid before provides important background for assessing the potential impact on participants’ first-aid knowledge and skills. A study conducted with vocational school students found that most did not receive first-aid training and had low intervention rates when encountering situations requiring first aid. Similarly, it reveals that there are high rates of participants who are hesitant to intervene in a person drowning in water or a person having an epileptic seizure.[22] At this point, they also cite studies showing that Basic Life Support skills increase the first-aid response rate. Significant data show that individuals without first-aid or inadequate training tend to abstain in emergencies and are reluctant to intervene.[22,23] Another study pointed out that early intervention increases the chance of survival in an emergency.[24]

Case-based learning has been widely recognized as an effective educational strategy for enhancing clinical reasoning and contextual understanding in health professions education.[25] By presenting learners with realistic scenarios, this approach facilitates the application of theoretical knowledge to practice. However, previous research has also indicated that when core competencies and structured content are consistent across training modalities, differences in learning outcomes may be minimal.[26] The present findings align with this perspective, suggesting that case-based training is practical, yet not uniquely influential, in improving first-aid self-efficacy. As a result of our evaluations, we have important data on the effects of three interactive first-aid training methods on university students’ first-aid knowledge levels. The first null hypothesis (H1.0), which stated that case-based first-aid application content does not affect students’ first-aid self-efficacy, was not rejected. After controlling for baseline self-efficacy levels, ANCOVA results indicated no statistically significant difference in post-test self-efficacy scores between students who received case-based training and those in the comparison groups. This finding suggests that, while case-based training contributed to improvements in first-aid self-efficacy, its effect was not significantly different from that of the other instructional approaches. Although case analyses reinforce theoretical knowledge, they alone are not enough to change students’ self-efficacy in applying their knowledge in a real crisis. Unlike similar studies in the literature, this result can be explained by the complexity of the case scenarios or the short duration of the application.[25,26]

Video-based education has been shown to enhance procedural learning by providing visual demonstrations, standardization of content, and opportunities for repeated viewing.[27] In first-aid and resuscitation training, video-based instruction has been reported to be as effective as traditional face-to-face teaching in improving knowledge and skills.[28] Consistent with these findings, the present study indicates that video-based training positively affects self-efficacy; however, its effects appear comparable rather than superior to those of other structured educational approaches. In a study conducted with third-year nursing undergraduate students, the students stated that there was no difference between video-assisted education and the traditional method, and that the group receiving the traditional method had higher knowledge scores than the group receiving video-assisted education.[29] In the study comparing the video demonstration and the traditional method, intramuscular and nasotracheal aspiration application skills in the ventrogluteal region were compared. As a result, it was reported that the skill scores of the group shown videos for two skills were more positive.[30] The second null hypothesis (H2.0), that video-based, structured first-aid application content does not affect students’ first-aid self-efficacy, was also not rejected. ANCOVA revealed that video-based training did not result in significantly higher post-test self-efficacy scores when baseline differences were controlled. This indicates that video-based instruction was as effective as the other training methods, but did not demonstrate a superior impact. This result is critical to our study’s objective of “determining the most effective modality,” as it shows that passive viewing methods (video) do not meet interactive expectations.

Drama-based and role-play methods are commonly associated with experiential learning, emotional engagement, and increased learner confidence, particularly in emergency and communication-focused training.[31] Simulation and role-play have also been linked to improvements in perceived competence and self-confidence in healthcare education.[32] However, the present findings suggest that while drama-based training is beneficial, its impact on first-aid self-efficacy is not significantly greater than that of case- or video-based instruction when equivalent educational content is delivered. Similarly, the third null hypothesis (H3.0), which posited that drama-based, structured first-aid application content does not affect students’ first-aid self-efficacy, could not be rejected. The adjusted post-test results showed no significant advantage of drama-based training over the other instructional techniques. These findings imply that drama-based applications support the development of first-aid self-efficacy, yet their effectiveness is comparable to that of alternative educational approaches. While drama methods are usually expected to elicit high participation, this result may have been due to students’ reluctance to role-play or to the intervention’s insufficient duration to create an emotional shift in the sample group. This supports the hypothesis that “exposure time” is as important as “modality” in education.

When examining post-test mean scores, a descriptive hierarchy emerged among the instructional modalities, with the case-based group achieving the highest scores (194.16 ± 25.17), followed by the video-based (190.61 ± 24.08) and drama-based (168.22 ± 54.37) groups. In contrast, the unstructured group remained the lowest (162.29 ± 45.19). Although these differences did not reach statistical significance, this numerical trend suggests that case-based learning may provide a slightly more robust framework for self-efficacy, likely due to its focus on critical thinking and real-world problem-solving. The relatively higher scores in the case- and video-based groups compared to drama might be attributed to the structured nature of these tools, which provide clear visual and analytical guidelines. Conversely, the high standard deviation observed in the drama-based group (SD = 54.37) indicates greater variance in student responses, suggesting that while some students thrived in an experiential environment, others may have felt less confident or required more time to adapt to active role-playing than to more structured methods. Taken together, the failure to reject all three null hypotheses indicates that case-, video-, and drama-based first-aid training approaches are equally effective in enhancing students’ first-aid self-efficacy. None of the instructional methods demonstrated statistical superiority when baseline self-efficacy levels were controlled. The small effect sizes observed across outcomes further support the conclusion that differences between instructional methods were negligible after controlling for baseline self-efficacy. The acceptance of the null hypotheses (H01, H02, and H03) indicates that no statistically significant difference was observed between the effects of case-, video-, and drama-based training on students’ first-aid self-efficacy (P > 0.05). However, from a pedagogical perspective, the lack of statistical superiority of one method over another suggests that all interactive modalities are inherently valuable and contribute uniquely to the learning process. The findings imply that while each method—be it through the analytical depth of case studies, the visual clarity of videos, or the experiential nature of drama—provides a distinct educational advantage, their impact on psychological constructs like self-efficacy may require more intensive or prolonged exposure to reach statistical significance. This “nonsignificant” result does not diminish the value of these interactive strategies; instead, it underscores that they are equally effective baseline tools, and their integration into a multimodal curriculum may be more beneficial than relying on a single approach.

From a theoretical perspective, this finding is consistent with Bandura’s self-efficacy theory, which emphasizes mastery experiences, feedback, and perceived competence as key determinants of self-efficacy, regardless of the specific instructional format.[33] As all training approaches in the current study incorporated opportunities for skill exposure and practice, it is unsurprising that similar gains in self-efficacy were observed across groups. An experimental study by Jallad and Işık[34] employed intervention and control groups to strengthen nursing students’ intravenous catheterization skills, with outcomes measured in terms of performance, self-confidence, satisfaction, and fear. Recent evidence highlights the effectiveness of immersive virtual simulation in nursing education. Chang et al.[35] demonstrated that students trained with a virtual simulation system achieved significantly higher scores in intravenous line insertion skills and greater satisfaction than those in the control group. In some studies, no significant difference was observed in academic achievement and skill scores between the intervention and control groups.[36,37,38] In a randomized controlled study using interactive education and demonstration, it was stated that the hand washing efficiency of students who received interactive education showed a significant increase compared to the control groups.[39] After the hand-washing program was implemented through role-play with preschool children, participants’ hand-washing frequency increased compared to nonparticipants.[40] In another study examining the effect of psychological first-aid training for students on disaster preparedness perceptions and self-efficacy, it was shown that after 6 weeks of training, students’ self-efficacy perceptions increased, as did their disaster preparedness perceptions.[41] In their study using the fire disaster simulation method, Park and Choi[42] reported that first-aid training significantly increased students’ self-efficacy, performance proficiency, and knowledge levels. A study conducted with health school students in nursing, Midwifery, emergency aid, and disaster departments found that students’ knowledge levels increased after the basic life support learning program, supporting the importance of education.[43] The general results of these studies show that appropriate pedagogical and interactive educational methods increase the effectiveness of education and are more effective in improving students’ knowledge, skills and attitudes. These findings may contribute to the development of more effective strategies in the design and implementation of educational programs. It emphasizes the importance of research in developing more effective health education strategies. In this context, using different methods in the design and implementation of educational programs may be more effective in improving students’ knowledge, skills, and attitudes. This study underscores the novelty of using interactive modalities in first-aid education, offering fresh insight into how active engagement fosters self-efficacy. The originality of this research lies in demonstrating that interactive participation itself, rather than the specific format, drives improvements in self-efficacy. This way, the uniqueness is framed around interactivity itself as a social innovative contribution. In the country where this study was conducted, first aid is taught using classical methods, and the relevant authorities decide how it should be taught. The results of this study can provide a driving force for policy development by these authorities or institutions. Furthermore, the technological dimension of these instructional methods has increasingly gained prominence in recent literature, signalling a paradigm shift in emergency training. The adaptability of these interactive techniques to online platforms and mobile learning environments offers a transformative potential for wider accessibility and scalability. Integrating such portable digital solutions into national curricula could bridge the gap between traditional classroom settings and modern, tech-driven pedagogical needs.[44,45,46]

This novel perspective suggests that the essence of interactivity (engagement, reflection, and practice) may be more influential than the medium through which it is delivered. By centring on interactive approaches, the study provides new evidence that active involvement is the key to adequate first-aid education. In line with recent high-impact literature, Kitapcioglu et al.[47] found that machine-guided virtual reality training can achieve learning outcomes comparable to those of educator-guided sessions within a metaverse environment. This suggests that interactive and technology-driven modalities, as explored in our study, are increasingly validated by contemporary research as viable alternatives to classical pedagogical approaches. Their findings further reinforce our argument that the shift toward innovative, digital, and autonomous learning platforms is essential for modernizing first-aid education and enhancing student engagement on a global scale.

Limitations and strengths

This study has some limitations regarding the generalizability of its findings. The sample consisted predominantly of female students and was conducted within health-related departments at a single university in Turkiye. Therefore, the results may not be fully representative of other academic disciplines, different gender distributions, or diverse cultural settings. Future research involving more diverse participant groups and multicenter designs would strengthen the external validity of these results. Furthermore, the gender imbalance (predominantly female) and the discipline-specific nature of the sample (health sciences) may influence the reproducibility of the study’s outcomes in mixed-gender groups or nonhealth populations. Therefore, the superiority of case-based learning observed in this study should be interpreted with caution when applied to different educational contexts.

This study stands out by comparing four distinct educational modalities-case-, video-, drama-based, and traditional instruction-providing a comprehensive analysis of pedagogical effectiveness in first-aid training. The use of a randomized design and the inclusion of psychological first-aid components reflect a modern, multidimensional approach to emergency preparedness.

Despite its contributions, this study has several limitations. First, the intervention was conducted over a specific, limited timeframe and lacked a longitudinal follow-up to assess the long-term retention of self-efficacy and skills. As the literature emphasizes, regular, continuous training is essential for maintaining high self-efficacy, particularly in high-stress situations such as disasters.[48] Therefore, the lack of continuous exposure remains a primary limitation; it is recommended that university students receive periodic reinforcement training throughout their education. Second, gender distribution was not perfectly balanced across groups, which may influence the generalizability of the findings regarding self-efficacy perceptions. Finally, while the study measured self-efficacy, future research should incorporate objective skill assessments in real-life or high-fidelity simulation settings to further validate the behavioural outcomes of these training modalities.

Finally, the lack of prospective registration in a public trial registry is a limitation of this study. Nevertheless, the research was conducted in strict adherence to the protocol approved by the institutional ethics committee, ensuring the integrity and transparency of the experimental process.

Conclusions

This study provides evidence-based insights to inform improvements in the quality of first-aid courses. The findings indicate that all the training approaches examined in the study contributed positively to participants’ first-aid self-efficacy. However, after controlling for baseline differences using ANCOVA, no single training technique demonstrated statistical superiority over the others. This suggests that the observed improvements in first-aid self-efficacy were comparable across the instructional methods.

The results indicate that case- and video-based, and traditional training approaches can be effective strategies for enhancing first-aid self-efficacy when implemented within a structured educational framework. Rather than emphasizing the dominance of a specific method, the present findings support the notion that multiple instructional techniques may yield similar educational benefits.

The current study primarily focused on fundamental components of first aid. Nevertheless, recent literature emphasizes that research addressing psychological first aid remains limited and should be integrated into basic first-aid education.[48,49] This research provides original evidence that interactive learning, regardless of modality, enhances self-efficacy in first aid. The novelty of the study rests in its focus on interactivity as the defining feature of practical training, reinforcing the adaptability of educational strategies. These findings highlight that the strength of first-aid education lies not in the format chosen, but in the interactive nature of the experience itself. Future experimental studies are therefore recommended to incorporate psychological first-aid elements alongside physical first-aid skills to promote a more comprehensive training model.

In addition, previous research has underscored the importance of institutional and legislative support in developing holistic first-aid programs. Consistent with this perspective, the present study provides evidence for coordinated efforts by educators, school administrators, and policymakers to strengthen first-aid education through comprehensive, sustainable training programs. Also, the findings underscore that various interactive first-aid training modalities-whether case, video, or drama-based-consistently meet health policy benchmarks for enhancing community self-efficacy, offering policymakers and educators the strategic flexibility to implement cost-effective, scalable, and adaptable prehospital emergency care programs.

Future research should transition from broad comparisons of instructional formats toward identifying the specific content components, optimal practice intensities, and longitudinal follow-up strategies that most effectively sustain first-aid self-efficacy. Furthermore, given the evolving nature of emergency care, integrating Psychological First Aid (PFA) into standard curricula remains a critical yet underexplored frontier.[49,50,51] Future experimental studies should investigate the impact of immersive technologies, such as virtual reality, and the inclusion of emotional resilience training to determine their roles in enhancing psychological preparedness. Additionally, longitudinal designs are recommended to evaluate the long-term retention of both procedural skills and decision-making confidence across diverse demographic groups.

AI policy

During the preparation of this work, the authors used AI (Grammarly) in order to improve the language and readability of the manuscript. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the publication’s content.

Ethical approval and/or ınstitutional approval

Ethical permissions were obtained from XXX University, Social and Human Sciences Research Ethics Committee (date: 25.04.2023; approval no. 01.37). Institutional permission was obtained from Tokat Gaziosmanpasa University, and written informed consent was obtained from the participants who agreed to participate in the study.

Author’s contributions

FA and BV: Study design. FA and BV: Data collection. BV, FA and AK: Literature search. FA and AK: Analyses. FA, BV and AK: Drafting manuscript.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. Representative examples of the pedagogical interventions, including sample clinical cases, drama scripts, and video sources, are provided in Table 1 and Appendix A to support the reproducibility of the study. For researchers requiring more extensive details, such as the full 6-week curriculum or comprehensive lesson plans, additional information is available from the corresponding author.

Conflicts of interest

There are no conflicts of interest to declare.

Supplementary Materials

Appendix A: Detailed Instructional Framework and Resources

Sample Case Scenario (Case-Based Group)

Scenario: A 5-year-old pediatric patient is eating hard candy when they suddenly become unable to cough or speak. The patient is clutching their throat (universal choking sign) and their perioral region is becoming cyanotic (turning blue).

Objective: Immediate recognition of airway obstruction and application of the Heimlich maneuver.

1. Initial Assessment: Students identify the difference between partial and total obstruction based on breath sounds and cyanosis.

2. Critical Decision Making: Determining the appropriate intervention for a pediatric vs. adult patient.

3. Procedural Application: Step-by-step cognitive rehearsal of the Heimlich maneuver (abdominal thrusts) until the object is expelled or the patient becomes unconscious.

4. Post-Event Care: Placing the patient in the recovery position and monitoring vital signs until EMS arrival.

Discussion Points: 1. Identifying signs of total vs. partial obstruction. 2. Step-by-step physical intervention. 3. Postintervention recovery position.

Discussion Facilitation: "What is the physiological risk of back blows in a total obstruction?" and "When exactly should CPR be initiated in this scenario?"

Video Sources (Video-Based Group)

The training utilized standardized videos from the Republic of Turkiye Ministry of Health - General Directorate of Emergency Health Services.

Source Link: Republic of Turkiye Ministry of Health - General Directorate of Emergency Health Services.[51]

Technical Specifications:

1. Resolution/Format: High-definition standardized instructional videos with native audio narration.

2. Content Alignment: Each of the 6 core competencies (basic life support, bleeding control, heat-related emergencies, etc.) was addressed via a dedicated 8–10 minute video module.

Integration Method:

1. Prevideo Briefing: 5 minutes of theoretical context provided by the instructor.

2. Observational Phase: Students watched the procedure twice; first for general flow, second for specific hand placement and timing (e.g., compression depth in CPR).

3. Guided Replication: Following the video, students practiced on mannequins while the instructor ensured the "visual model" from the video was accurately imitated.

Drama Script Outline (Drama-Based Group)

Scenario: Post-Traffic Accident Trauma (Bleeding & Shock)

Role 1 (The Rescuer): Must perform a 360-degree scene safety check, prioritize victims using triage principles, and apply a pressure bandage or tourniquet while maintaining verbal contact with the victim.

Role 2 (The Victim): Provided with a "Character Card" indicating: "You are confused, complaining of extreme thirst, and showing rapid, shallow breathing. You must simulate heavy bleeding from the femoral artery using simulated moulage."

Environmental Fidelity (Sensory Cues):

1. Auditory: High-volume playback of heavy city traffic and intermittent emergency sirens.

2. Visual: Use of red fluid (moulage) for realistic bleeding and medical blankets for shock management.

3. Debriefing: A 15-minute "Reflective Practice" session followed each drama, focusing on the emotional stress felt during the rescue and the physical "embodiment" of the first-aid steps.

Objective Structured Clinical Examination (OSCE) Protocol

To validate the skills acquired through the modalities above, a final assessment was conducted:

Station 1: Adult Cardiopulmonary Resuscitation (CPR) and AED use.

Station 2: Bleeding Control (Pressure bandage and Tourniquet application).

Station 3: Management of Airway Obstruction (Heimlich Maneuver).

Evaluation: Two independent observers used a standardized checklist (Pass/Fail) based on the Turkish Ministry of Health First Aid Guidelines. All groups achieved a 100% completion rate for mandatory safety steps.

Funding Statement

Nil.