Table 1. Characteristics of studies included in the systematic review of health effects of first aid by lay responders in low-resource settings and underserved populations.
| Medical condition and study | Country | Study population and age | Study design and study period | Intervention | Control | Primary outcome and effect size | Quality ratinga |
|---|---|---|---|---|---|---|---|
| Cardiac arrest | |||||||
| Roberts et al., 199932 | United Kingdom | Population: approximately 30 000 people. Age: NR | Case series. Study period: 1 year | Intervention: training on basic life support for lay first responders. Participants: 83 people trained; 134 cardiac arrest patients treated | Control: none | Difference in mean response time to cardiac arrest calls between first responders and ambulances: 7.6 minutesb | Weak |
| Page et al., 200033 | USA and international airline flight routes | Population: 627 956 flights, 70 801 874 passengers. Age: mean 58 years, patients treated | Case series. Study period: 12.5 months | Intervention: appropriate use of automated external defibrillator on flights. Participants: 24 000 flight attendants trained; 200 patients treated, 15 of whom were defibrillated | Control: none | Percentage of patients alive at hospital discharge: 99/200 patients were unconscious; 40% (6/15 patients) survived neurologically intact to hospital dischargeb | Weak |
| Rørtveit & Meland, 201034 | Norway | Population: 4400 people. Age: 36–92 years, patients treated | Case series. Study period: 5 years | Intervention: basic life support and defibrillation initiated by laypeople. Participants: 42 people trained; 17 patients treated among 24 cardiac arrest calls | Control: none | Median time from first responder arrival until ambulance or doctor arrival: 22.5 minutesb | Weak |
| Nielsen et al., 201335c | Denmark | Population: 42 000 community members, 600 000 seasonal tourists annually. Age: > 15 years | Before-and-after study, uncontrolled. Study period: 1 year | Intervention: community-wide basic life support and automated external defibrillator use. Participants, number of people trained and treated: NR | Control: none | Percentage of community members willing to use an automated external defibrillator on a stranger: 63% (520/824 people) pre-intervention versus 82% (669/815 people) post-intervention (χ2 test P < 0.0001; OR: 2.86; 95% CI: 2.26–3.63)d | Weak |
| Burns | |||||||
| Sunder & Bharat, 199836 | India | Population: unknown. Age: 53.5% of inpatients age 25–35 years (frequencies not specified) | Before-and-after study, uncontrolled. Study period: 4 years | Intervention: occupational burn prevention and treatment education. Participants: 590 steel workers trained; 142 inpatients and 673 outpatients treated | Control: none | Percentage of burn patients with < 20% total body surface area burns receiving appropriate first aid: 37.8% (14/37 patients) pre-intervention versus 25.0% (4/16 patients) post-intervention; (OR: 3.75; 95% CI: 0.88–19.53)d | Weak |
| Skinner, et al., 200437 | New Zealand | Population: NR. Age: pre-intervention patients, 3 months to 77 years; post-intervention patients, 3 months to 83 years | Before-and-after study, uncontrolled. Study period: two 4-month study intervals, 44 months apart | Intervention: public first aid campaign for burn injuries. Participants: general public; number of people treated: NA | Control: none | Percentage of patients receiving adequate first aid: 33% (11/33e people) pre-intervention versus 61% (22/36e people) post-intervention (P = 0.02) among Pacific Islanders; 25% (6/24e people) versus 48% (13/27e people) post-intervention (P = 0.08) among Maori people | Moderate |
| Malaria | |||||||
| Kidane & Morrow, 200038 | Ethiopia | Population: 37 regions, each with a population of 1000–3000 people; 14 001 children aged < 5 years. Age: < 5 years | Randomized controlled trial. Study period: 12 months | Intervention: peer education for mothers on recognition and treatment of paediatric malaria. Participants: 12 regions with 6383 children aged < 5 years; number of children treated: NR | Control: no peer education. Participants: 12 regions with 7294 children aged < 5 years; number of children treated: NR | Absolute rate reduction in all-cause mortality in children < 5 years: 20.4 per 1 000 (95% CI: 13.9–26.9) | Weak |
| Ajayi et al., 200839 | Nigeria | Population: 147 847 people, including 33 126 children and 33 576 women of childbearing age. Age: ≤ 10 years | Randomized controlled trial. Study period: 12 months | Intervention: peer education for mothers on paediatric malaria recognition and treatment. Participants: 330 mothers trained; 247 paediatric malaria cases treated | Control: no peer education. Participants: 281 mothers, 266 paediatric malaria cases | Percentage of children receiving chloroquine according to guideline on febrile illness for children at home: 2.6% (3/116 children) pre-intervention versus 52.3% (69/132 children) post-intervention (P < 0.001) in intervention group; 4.1% (3/72 children) pre-intervention versus 15.8% (9/57 children) post-intervention (P = 0.05) in control group |
Weak |
| Kouyaté et al., 200840 | Burkina Faso | Population: NR. Age: < 5 years | Cluster randomized controlled trial. Study period: 2 years | Intervention: community-based malaria education and management. Participants: 70 women group leaders trained across 6 villages; 542 children treated at baseline and 496 children treated at follow-up | Control: no community-based malaria education and management. Participants: seven villages; 541 children treated at baseline and 510 children at follow-up | Percentage of children younger than 5 years with malaria with moderate to severe anaemiaf: 28% (152 children) pre-intervention versus 17% (83 children) post-intervention in intervention group; 30% (162 children) versus 15% (74 children) post-intervention in control group (P = 0.32; OR: 1.18; 95% CI: 0.83–1.69)d | Weak |
| Ndiaye et al., 201341 | Senegal | Population: 40 000 people. Age: all ages | Case series. Study period: 4 years | Intervention: nurse-led education on malaria recognition and treatment. Participants: 31 community medicine distributors and 21 community health workers trained; 5384 consultations given by community medicine distributors and 16 757 by community health workers | Control: none | Percentage of eligible patients receiving rapid malaria tests: 93.5% (5036/5384 patients) treated by community medicine distributors; 56.8% (9518/16 757 patients) treated by community health workersb | Weak |
| Tobin-West & Briggs, 201542 | Nigeria | Population: 2187 people. Age: < 5 years | Before-and-after, controlled. Study period: 12 months | Intervention: community-based education on treatment of malaria. Participants: 184 mothers trained pre-intervention and 173 trained post-intervention; number treated: NR | Control: no training or drugs provided. Participants: 184 mothers pre-intervention and 169 post-intervention; number treated: NR | Percentage of mothers reporting their child was cured of malaria: 47.3% (87 mothers) pre-intervention versus 84.4% (146 mothers) post-intervention in intervention group (P < 0.0001); 50.0% (92 mothers) pre-intervention versus 49.1% (83 mothers) post-intervention in control group (P = 0.94) | Weak |
| Warsame et al., 201643 | Ghana, Guinea-Bissau, Uganda and United Republic of Tanzania | Population: 26 594 households, 346 villages; 58 771 children aged < 5 years; intervention: 141 clusters,12 297 households; control: 136 clusters, 10 531 households. Age: < 5 years | Cluster randomized controlled trial. Study period: 19 months | Intervention: community-based treatment for severe malaria before hospital referral. Participants: 687 mothers, traditional healers and others trained; 2464 children treated | Control: usual practice from community health workers. Participants: 1469 children treated | Odds ratio of initiation of malaria treatment in the community before hospital referral for severe malaria: 1.84 (95% CI: 1.20–2.83) trained mothers versus controls | Moderate |
| Kitutu et al., 201744 | Uganda | Population: 472 629 people; population aged < 5 years: NR. Age: < 5 years | Before-and-after, controlled. Study period: 12 months | Intervention: community-based treatment of various paediatric illnesses. Participants: owners and attendants at 61 drug shops trained; 212 caretaker–child pairs treated at baseline and 285 pairs treated at endline | Control: no community-based training. Participants: 23 drug shops; 216 caretaker–child pairs treated at baseline and 268 pairs treated at endline | Percentage of children younger than 5 years receiving guideline-based treatment for uncomplicated malaria: 8.3% (11/133 children) pre-intervention versus 57.5% (108/188 children) post-intervention in intervention group; 31.9% (38/119 children) pre-intervention versus 0.9% (1/112 children) post-intervention in control group. Difference between groups: 80.2% (95% CI: 53.2–107.2) of children received treatment |
Weak |
| Linn et al., 201845 | Myanmar | Population: 978 735 people. Age: < 5 years (9.5%); 5–14 years (18.6%); ≥ 15 years (72.0%) | Cohort study, retrospective. Study period: 1 year | Intervention: screening, testing and management of malaria by village health volunteers, with referrals as needed. Participants: 270 155 volunteers trained; 23 503 (80.9%) patients received complete treatment | Control: similar to intervention, but conducted by basic health staff. Participants: 708 580 volunteers trained; 64 879 patients (88.2%) received complete treatment | Adjusted prevalence ratio of receiving malaria treatment among eligible patients in intervention versus control: 1.02 (95% CI: 1.015–1.020) | Weak |
| Green et al., 201946 | Zambia | Population: intervention area of 54 000 people in Serenje district. Age: < 5 years | Before-and-after study, uncontrolled. Study period: 12 months | Intervention: treatment and transport of children with severe paediatric malaria by community volunteers. Participants: 180 Safe Motherhood Action Group volunteers and 45 volunteers trained in integrated community case management, and 66 bicycle ambulance riders trained in emergency transport; 224 children treated before intervention and 619 children during intervention | Control: none | Malaria case fatality rate in children younger than 5 years: 8% (18/224 children) before intervention: 0.5% (3/619 children) during interventionb | Weak |
| Minn et al., 201947 | Myanmar | Population: 257 700 people. Age: all ages | Cross-sectional. Study period: 1 year | Intervention: malaria screening, diagnosis and treatment services by integrated community malaria volunteers, with referrals as appropriate. Participants: 632 volunteers trained; 2279/2881 (79%) of malaria-positive patients treated | Control: care from basic health staff at health posts | Adjusted probability ratio of receiving incorrect treatment for malaria from volunteers versus care at health posts: 0.5 (95% CI: 0.30–0.83) | Weak |
| Malnutrition | |||||||
| Alé et al., 201648 | Niger | Population: intervention group, 37 389 people and 9908 children aged < 5 years; control group, 33 449 people and 8867 children aged < 5 years. Age: < 5 years | Non-randomized cluster trial. Study period: 11 months | Intervention: training on screening for severe acute malnutrition by mothers and caretakers. Participants: 12 893 mothers and caretakers trained; 1371 children admitted to malnutrition treatment | Control: screening for severe acute malnutrition by community health workers. Participants: 36 community health workers trained; 988 children admitted to malnutrition treatment | Percentage of children hospitalized for malnutrition treatment: 7.2% (99/1371 children) in intervention group versus 11.8% (117/988 children) in control group. Relative risk ratio of hospitalization: 0.61 (95% CI: 0.47–0.79); risk difference: −4.62% (95% CI: −7.06 to −2.18) | Weak |
| Opioid poisoning | |||||||
| Walley et al., 201349 | USA | Population: 30% of population of Massachusetts State. Age: NR | Time-series analysis. Study period: 8 years, 2002–2009 | Intervention: overdose education and naloxone distribution. Participants: 2912 people enrolled in training; 327 rescue attempts made | Control: none | Adjusted rate ratio relative to reference population with 0 enrolments per 100 000 population: 0.73 (95% CI: 0.57–0.91) in regions with 1–100 enrolments in training per 100 000 population; 0.54 (95% CI: 0.39–0.76) in regions with > 100 enrolments in training per 100 000 population | Weak |
| Bird et al., 201650 | Scotland, United Kingdom | Population: about 5.1 million people; affected sub-population size: NR. Age: NR | Before-and-after study, uncontrolled. Study period: 2006–2010 pre-intervention, 2011–2013 post-intervention | Intervention: nationwide education on opioid overdose and naloxone distribution programme. Participants: 11 898 kits issued by community and prisons; numbers of patients treated unknown | Control: none | Percentage of opioid-related deaths with a 4-week antecedent of prison release: 9.8% (193/1970 people) pre-intervention versus 6.3% (76/1212 people) post-intervention (absolute difference: 3.5%; 95% CI: 1.6–5.4%) | Moderate |
| Irvine et al., 201951 | British Columbia, Canada | Population: not specified (population of British Columbia). Age: NR | Cohort study, retrospective, with Markov chain modelling. Study period: about 20 months (Apr 2016–Dec 2017) | Intervention: provincial distribution of naloxone kits, as well as provincial overdose prevention and supervised consumption services and opioid agonist therapy. Participants: 88 300 naloxone kits distributed in 2017; number of patients treated unknown | Control: none | Number of opioid-related-deaths averted:1650 (95% CrI: 1540–1850); 11 kits used per death averted (95% CrI: 10–13) | Moderate |
| Mahonski et al., 202052 | Maryland, USA | Population: 1139 people with opioid poisoning and community naloxone administration. Age: all ages, mean age 34.3 years | Cohort study, retrospective. Study period: 24 months, Jan 2015–Oct 2017 | Intervention: overdose education and naloxone distribution. Participants: 70 992 people trained in 2015–2017, including 6031 law enforcement officers; 1139 patients treated | Control: none | Percentage of opioid poisoning cases reversed: 79.2% of 886 poisoning cases overall; decrease from 82.1% (96/117 patients) in 2015 to 76.4% (441/577 patients) in 2017 (P = 0.04) | Weak |
| Naumann et al., 201953 | North Carolina, USA | Population: not specified (population of North Carolina State). Age: NR | Before-and-after, uncontrolled. Study period: 2000–2016 | Intervention: overdose education and naloxone distribution. Participants: 39 449 naloxone kits distributed; numbers treated unknown | Control: none | Rate ratio of opioid poisoning deaths in intervention counties compared with counties not receiving naloxone kits: 0.90 (95% CI: 0.78–1.04) in counties with 1–100 kits distributed per 100 000 population; 0.88 (95% CI: 0.7–1.02) in counties with > 100 kits distributed per 100 000 population | Weak |
| Papp et al., 201954 | North-east Ohio, USA | Population: 291 people who use opioids. Age: median 34 years | Cohort study, retrospective. Study period: 3 and 6 months from hospital discharge | Intervention: hospital-based overdose education and naloxone distribution. Participants: 208 (71%) overdose survivors trained; treatment outcome reported among trainees | Control: no overdose education or naloxone distribution. Participants: 83 overdose survivors untrained; number of patients treated: NA | Percentage of patients experiencing repeat overdose-related emergency department visit, hospitalization or death (composite of events): 6.0% (5/83 patients) in control group versus 7.7% (16/208 patients) in intervention group over 3 months (P = 0.9); 4.8% (4/83 patients) in control group versus 6.7% (14/208 patients) in intervention group over 6 months (P = 0.99) | Weak |
| Rowe et al., 201955 | San Francisco, USA | Population: not specified (population of San Francisco). Age: NR | Before-and-after, uncontrolled. Study period: 2014–2015 | Intervention: overdose education and naloxone distribution. Participants: 1023 overdose education and naloxone distribution trainees in 2014 and 1123 trainees in 2015; 326 people trained in 2014 and 504 trained in 2015 | Control: none | Number of opioid poisoning reversals reported: 326 in 2014 versus 504 in 2015 (P < 0.001) | Weak |
| Paediatric communicable diseases | |||||||
| Bang et al., 199456 | India | Population: 48 377 people in 58 villages in intervention area; 34 856 people in 44 villages in control area. Age: < 5 years | Non-randomized cluster trial. Study period: 3 years | Intervention: management of childhood pneumonia by lay community members. Participants: 30 paramedical workers, 25 village health workers and 86 traditional birth attendants trained (only traditional birth attendants met layperson inclusion criterion); traditional birth attendants managed 651 cases of pneumonia among children aged < 5 years and 50 cases among neonates | Control: existing care. Participants: no community members trained; number of children treated unknown | Pneumonia case fatality rate in children younger than 5 years: 2.0% (13/651 children) with care by traditional birth attendants versus 13.5% with existing care (frequencies: NR) | Moderate |
| Holloway et al., 200957 | Nepal | Population: 4 districts of 134 000–232 000 people each; population aged < 5 years unknown. Sample frame of 2231 households with a child aged < 5 years old who had acute respiratory infection in last 2 weeks. Age: < 5 years | Before-and-after, controlled. Study period: about 6 months | Intervention: community-wide education programme on recognizing and treating acute respiratory infections. Participants: community exposed to public campaign; 200 children aged < 5 years with severe acute respiratory infection treated | Control: existing care. Participants: community not exposed to campaign; 187 children aged < 5 years with severe acute respiratory infection treated | Absolute difference in percentage of children younger than 5 years with severe acute respiratory infection receiving consultation at a health post: 12.6 % (test of interaction with intervention versus control group P = 0.01) | Weak |
| Yansaneh et al., 201458 | Sierra Leone | Population: projected 57 000–76 000 children (19% of 300 000–400 000 people). Age: < 5 years | Before-and-after, controlled. Study period: 2 years | Intervention: treatment and referral of common childhood illnesses by lay volunteers. Participants: 2129 volunteers trained; 1980 children brought for medical care at baseline and 1657 patients at endline | Control: existing care. Participants: no people trained; 1962 patients brought for care at baseline and 2102 patients at endline | Odds ratio of appropriate treatment: 0.45 (95% CI: 0.21–0.96) for childhood diarrhoea; 0.65 (95% CI: 0.32–1.34) for malaria; 2.05 (95% CI: 1.22–3.42) for pneumonia | Weak |
| Langston et al., 201959 | Province of Tanganyika, Democratic Republic of the Congo | Population: 2 649 317 people. Age: NR | Non-randomized cluster trial. Study period: 11 months | Intervention: simplified teaching of integrated community case management for uncomplicated malaria, pneumonia and diarrhoea for children aged 2–59 months. Participants: 1600 people trained and 78 lay providers assessed; 78 children assessed |
Control: standard teaching for integrated community case management of uncomplicated malaria, pneumonia and diarrhoea. Participants: 74 lay providers assessed; 74 children assessed | Adjusted odds ratio of correct referral of children with danger signs: 24.2 (95% CI: 1.9–300.2) | Moderate |
| Oresanya et al., 201960 | Niger State, Nigeria | Population: 899 sick children from caregiver survey included at baseline and 680 sick children at endline. Age: < 5 years | Before-and-after, uncontrolled. Study period: from baseline 2014 to endline 2017 | Intervention: treatment and management of paediatric diarrhoea, pneumonia and fever by volunteer community caregivers. Participants: 1320 volunteers trained; 161 patients treated | Control: none | Percentage of children younger than 5 years brought for care to an appropriate provider: for fever, 78% (322/413 children) at baseline versus 94% (283/301 children) at endline, (P < 0.01); for diarrhoea, 72% (269/374 children) at baseline versus 91% (274/300 children) at endline (P < 0.01);for pneumonia, 76% (262/343 children) at baseline versus 89% (267/301 children) at endline (P < 0.05) | Moderate |
| Snakebites | |||||||
| Sharma et al., 201361 | Nepal | Population: 60 759 people pre-intervention; 59 383 people post-intervention. Age: NR | Before-and-after study, uncontrolled. Study period: Nov–Dec 2003 versus Nov–Dec 2004 | Intervention: community-wide campaign to promote snakebite awareness and rapid transport. Participants: 10 motorcycle drivers trained in each of four subregions; two to three public snakebite awareness programmes per subregion, numbers attending unspecified; leaflets, banners and posters distributed; 122/305 snakebite patients transported by motorcycle pre-intervention, 143/187 during intervention | Control: none | Snakebite case fatality rate: 10.5% (32/305 people) pre-intervention versus 0.51% (187 people) post-intervention; relative risk reduction: 0.95 (95% CI: 0.70–0.99); absolute risk reduction: 10.04 (95% CI: 7.38–15.72)e | Weak |
| Trauma | |||||||
| Husum et al., 200362c | Cambodia and Iraq | Population: NR. Age: NR | Before-and-after study, uncontrolled. Study period: 5 years from 1997 to 2001 | Intervention: trauma first aid administered by lay responders. Participants: 135 paramedics and 5237 lay responders trained; 224/1285 emergency medical patients and 1061/1285 trauma patients treated | Control: none | Absolute change in physiological severity score from prehospital to hospital arrival: 0.3 at baseline versus 0.7 after intervention; difference in differences: 0.4 (95% CI: 0.2–0.6). | Strong |
| Saghafinia et al., 200963c | Iran (Islamic Republic of) | Population: not specified. Age: mean 31.9 years | Cohort study, prospective. Study period: 4 years | Intervention: pre-hospital first aid provided by lay individuals. Participants: 4834 lay villagers, nomads and various clinicians trained; 152/288 patients received prehospital care; 63/288 patients died before reaching hospital | Control: no prehospital treatment of injured people; patients moved directly to the hospital. Setting same as intervention group. Participants: no people trained; 73/288 patients sent directly to hospital. | Mean physiological severity scores: 6.40 prehospital versus 7.43 at hospital arrival (95% CI: −0.72 to −0.45) in intervention group; 5.97 in control group | Weak |
| Murad et al., 201264c | Iraq | Population: NR. Age: mean 26 years in survivors, 27 years in non-survivors | Before-and-after study, uncontrolled. Study period: 10 years | Intervention: prehospital trauma care delivered by lay responders. Participants: 7000 layperson first helpers trained; 2788 patients treated | Control: none | Mortality among trauma patients receiving treatment: 17% (95% CI: 15–19) pre-intervention versus 4% (95% CI: 3.5–5) post-intervention (frequencies: NR) | Moderate |
| Various emergencies | |||||||
| Lavallée et al., 199065 | Canada | Population: about 3000 people. Age: NR | Before-and-after study, controlled. Study period: 1 year | Intervention: distribution of medical kits and first aid training to Indigenous hunters in wilderness camps. Participants: 210 volunteers trained (49% participation rate across communities); number of people treated unknown | Control: no medical kits and first aid training. Setting same as intervention group. Participants: number of people trained NA; number of people treated: NA | Percentage of emergency health cases managed at wilderness hunt camps with kit: 60% versus 36% without kitb (frequencies: NR) | Weak |
CI: confidence interval; CrI: credible interval; NA: not applicable; NR: not reported; OR: odds ratio.
a We used the Effective Public Health Practice Project quality tool to assess internal and external validity, selection and measurement biases, and confounding factors.30
b Test of significance was not reported and we could not compute significance appropriately from the reported data.
c We retrieved multiple papers regarding the same study. See the authors' data respository.17
d We computed Fisher exact test using the reported data.
e We computed values based on the reported data.
f Haematocrit ≤ 24%.