First aid training in conflict zones: An interventional training study and a post-training knowledge assessment

Abstract

Background

In conflict-affected regions such as Syria, where health systems are severely disrupted, first aid training for laypersons is a critical intervention to reduce preventable mortality. This study aimed to evaluate Post-training theoretical knowledge of Syrian university students regarding the principles of First Aid.

Methods

An interventional training study was conducted in Swaida, Syria, in April 2025. University students (n=98 enrolled, n=55 analyzed) participated in a 10-hour, evidence-based course aligned with international guidelines. Post-training knowledge was assessed using a validated 14-question instrument. Data were analyzed using non-parametric tests (Kruskal-Wallis, Mann-Whitney U, Spearman’s correlation).

Results

Participants demonstrated a high level of post-course knowledge, with a median score of 13 (IQR: 12-13) and 75% scoring above 12 points. No statistically significant differences in scores were found between students from different faculties (p=0.051) or between those with and without prior training (p=0.461). A moderate positive correlation existed between academic year and test score (r=0.425, p<0.01). The most frequent knowledge gaps pertained to the management of shock and poisoning.

Conclusions

A structured first aid course is important for theoretical knowledge among students in a conflict setting, demonstrating potential to build equitable, community-level emergency response capacity. These findings support the strategic integration of context-adapted first aid education into public health initiatives in crisis-affected regions to strengthen resilience and mitigate the health consequences of conflict.

Keywords

first aid training conflict-affected regions emergency preparedness

Introduction

First aid constitutes the initial and immediate care administered in response to an acute injury or medical emergency. This fundamental intervention, applicable across diverse settings and potentially delivered by any individual—including through self-administration—aims to preserve life, mitigate the progression of a condition, and facilitate recovery until qualified medical assistance arrives.^1,2

As defined by the 2020 International Consensus on First Aid Science with Treatment Recommendations, first aid should be medically sound, based on the best available scientific evidence, universal, and actively promoted; consequently, everyone should learn first aid and be prepared to act.¹

Countries experiencing armed conflict, such as Syria, face profound disruptions to health systems, including the destruction of medical infrastructure, loss of healthcare personnel, and restricted access to emergency care. In such environments, first aid training for laypeople and community responders becomes essential to reduce preventable deaths and morbidity from trauma and acute illness, given that immediate professional medical assistance is often unavailable.^3,4 Medical literature emphasizes that training civilians in basic first aid—such as safe scene management, airway protection, bleeding control, and rapid casualty transport—can optimize point-of-injury care while minimizing responder risk in humanitarian settings.³

The need is further amplified by high rates of civilian casualties, displacement, and the deliberate targeting of healthcare workers and facilities, as documented in Syria and similar conflict zones.^5,6 As humanitarian responses increasingly rely on local actors and informal networks, scalable and context-adapted first aid education is critical for managing both physical and psychological emergencies.^7,8 Evidence from randomized trials and systematic reviews confirms that first aid training for laypeople increases knowledge, skills, and self-efficacy, all of which are vital for effective prehospital care in resource-constrained and insecure settings.⁴

The implementation of effective first aid correlates significantly with reduced morbidity and mortality rates. Appropriate pre-hospital care is instrumental in enhancing the likelihood of a more rapid and complete recovery. A seminal 1994 study by Hussain and Redmond indicated that approximately 39% of pre-hospital deaths resulting from accidental trauma could have been prevented through the timely and correct administration of basic first aid measures.⁹ This finding underscores the substantial impact of first aid on improving population health outcomes and reducing mortality.

The aim of the current study to report the findings of evaluating the knowledge toward first aid amongst participants enrolled in an evidence-based first-aid course in Syria, a country went through over a decade of continuous conflict. The current study provide am updated structured guide for those want to educate college students on First Aid. The study investigated how participants’ knowledge through a validated assessment tool reported in previous studies.

Methods

Study setting

This an interventional training study evaluated the post training knowledge retention regarding first aid principles among university students from various faculties in Swaida, a major city in southern Syria. Participants were students attending various universities across the country. The course was conducted from April 6 to April 17, 2025. Participants’ knowledge of first aid principles was assessed on the final day using a validated questionnaire employed in a prior related study.¹⁰

Course sessions

The instructional sessions were held at Platform Center, located in Swaida City Center, an educational facility providing services to university students in the region. The venue hosts diverse educational courses, not exclusively those for health personnel. Training materials included educational and medical manikins for practicing cardiopulmonary resuscitation and the Heimlich maneuver, alongside medical equipment such as stethoscopes, various types of sphygmomanometers, oximeters, and syringes of different sizes. Each participant group received ten hours of instruction on first aid principles, aligned with the 2024 American Heart Association and American Red Cross Guidelines for First Aid² supplemented with additional resources. The instruction was divided into five sessions as follows.

1- First session (An introduction to First Aid and How to take the vital signs properly – 2 hours): This session covered fundamental first aid principles and presented scenarios illustrating common emergency situations that would be addressed throughout the course. The instructor emphasized the DR-ABC algorithm for managing emergencies.¹¹ Additionally, vital signs—including heart rate, respiratory rate, blood pressure, and temperature—were discussed with attention to variations across different conditions. Practical training was provided on accurately measuring blood pressure and assessing heart and respiratory rates.¹²

2- Second session (CPR “Cardio-Pulmonary Resuscitation” and Loss of Consciousness – 2 Hours): Participants received detailed instruction on CPR techniques aligned with the latest guidelines (reference). Hands-on practice ensured proficiency in performing CPR correctly. Furthermore, students were trained in appropriate responses when encountering patients who have lost consciousness.^2,13

3- Third session (Circulatory Emergencies, Acute Coronary Syndrome and Types of Bleeding – 2 hours): Following an overview of circulatory system anatomy, participants learned to identify early signs of myocardial infarction and distinguish between stable and unstable angina pectoris. They were also instructed on appropriate interventions prior to ambulance arrival in both scenarios. The session concluded with training on managing various types of bleeding effectively.^2,14,15

4- Fourth session (Respiratory Emergencies – 2 hours): Following instruction on respiratory anatomy and indicators of respiratory distress, participants received training on the appropriate management of respiratory emergencies, including choking, asthma attacks, epiglottitis, and pneumothorax. Detailed information regarding symptoms and intervention techniques was provided to ensure accurate and effective responses. This session also included practical training, during which students learned how to perform the Heimlich maneuver in cases of complete airway obstruction, as well as appropriate maneuvers for other types of airway obstruction.¹⁶

5- Fifth session (Fractures, Burns, poisoning, Traumatized patients and taking venous blood samples – 2 hours): In the final session of the course, participants were instructed on the fundamental principles of managing traumatized patients in emergency settings. This included methods for patient transport and identification of fracture signs. Additionally, participants were educated about various degrees of burns and their corresponding treatment protocols. The session also covered poisoning caused by animal and insect bites, chemicals, and drugs. Finally, under strict supervision from the trainer, participants practiced venous blood sampling using 3ml syringes.²

The course was delivered by three certified medical doctors holding Bachelor of Medicine degrees and one certified nurse with over fifteen years of emergency room experience. Upon completing the final session, participants received a test paper containing an informed consent form to address ethical considerations. All attendees provided written informed consent, permitting the analysis of their responses and the publication of anonymized results. Details regarding the development of the first aid curriculum, including which components of existing curricula were adapted and the rationale for these adaptations, are provided in the supplement.

Evaluation tool and inclusion criteria

Prior to the main assessment, demographic questions collected participant characteristics, including gender, age, academic year, faculty affiliation, and any prior first aid training. To ensure reliable results comparable with other studies and to evaluate post-training knowledge, a 14-question validated instrument from a previously published study was administered.¹⁰

This tool assessed theoretical knowledge only. Although practical skills were not formally evaluated, the primary course objective was to establish a comprehensive understanding of medical emergencies and their management. Despite this, all participants performed the Heimlich maneuver and CPR on medical manikins, drew venous blood samples from one another, and measured vital signs under the direct supervision of the authors.

The trainers established the following eligibility criteria for data inclusion: only participants who attended at least three of the five sessions were considered. From the 98 enrolled participants, 43 were excluded—35 for attending fewer than three sessions (primarily due to travel obligations at the start of the academic semester) and eight for non-response.

Data collection and sample size

Participants were recruited by distributing a Google form through multiple social media groups for students from Swaida. The form detailed the course content and session dates. At the end of the registration period, 98 students had enrolled. Although the course was openly advertised across major platforms for all university students in Swaida, enrollment reached only 98 individuals. To avoid selection bias, no specific student groups were targeted to increase enrollment or statistical power.

Participants were divided into two groups (Group 1: 44 students; Group 2: 54 students) to ensure effective instruction without disruption from a high volume of attendees. Both groups received identical content from the same presenters.

Ethical considerations

Written informed consent for publishing anonymized data was obtained from all participants, who were also informed of their right to withdraw without penalty. The study was approved by the Platform Center’s executive management. Ethical approval was obtained from the Swaida Health Directorate, affiliated with the Ministry of Health (ID: 273).

To ensure not influencing the results, the person responsible for the analysis was blinded to the participants. Each participant was given an ID number during the analysis of the data to ensure internal validity, and consequently, external validity of the results.

Data analysis

Data analysis was conducted using IBM SPSS Statistics version 26. Normality was assessed via skewness and kurtosis tests; results indicated non-normal distribution. Nominal and categorical variables are presented as frequencies and percentages; continuous variables are reported as medians with interquartile ranges. Independent-Samples Kruskal-Wallis Test was employed to compare scores among students from different universities. Mann-Whitney U Test assessed differences in scores between males and females as well as between those with or without prior first aid training. Spearman’s correlation coefficient evaluated associations between academic year and participant scores. Statistical significance was set at P ≤ 0.05. Power analysis was performed using G Power software and the results are exhibited in the supplementary file.

Results

Of the 98 participants initially enrolled in the First Aid course, only 55 participants (15 males and 40 females) attended at least three sessions; consequently, only these individuals were included in the analysis. The median age of the participants was 21 years, with an interquartile range of 20 to 22 years. Nearly half of the participants were students or graduates from the Faculty of Medicine (45.5%). Additionally, six participants (10.9%) and four participants (7.3%) were students or graduates from the Faculties of Pharmacy and Dentistry, respectively. The remaining participants represented various other faculties, including Architecture, Nursing, Arts, Information Technology, Civil Engineering, Health Sciences, Economics, and Physical Therapy.

Only four participants reported having previously attended a First Aid course; the majority (92%) did not report any prior training. Detailed characteristics of the participants are presented in Table 1.

Table 1.

Participants characteristics (43 participants were excluded, leaving 55 in the final analysis).

The characteristics	Number (%) OR median (IQR*)
Gender
Male	15 (27.3%)
Female	40 (72.7%)
Faculty
Faculty of Medicine	25 (45.5%)
Faculty of Pharmacy	6 (10.9%)
Faculty of Dentistry	4 (7.3%)
Other Faculties**	20 (36.4%)
Age (in years)	21 (20 - 22)
Academic Year of the participant
Less than University	1 (1.8%)
1^st Academic Year	10 (18.2%)
2^nd Academic Year	9 (16.4%)
3^rd Academic Year	9 (16.4%)
4^th Academic Year	19 (34.5%)
5^th Academic Year	2 (3.6%)
Graduated from the university	5 (9.1%)
Have you ever attended any First Aid Courses?
Yes	4 (7.3%)
No	51 (92.7%)

*IQR: Interquartile Range.

**Other faculties include: Faculty of Architect, Faculty of Nursing, Faculty of Art, Faculty of Information technology, Faculty of Civil Engineering, Faculty of Health Science, Faculty of Economics and Faculty of Physical Therapy.

The majority of students demonstrated a good level of knowledge regarding First Aid principles, with 75% scoring above 12 points. The median score achieved was 13, with an interquartile range of 12 to 13. The distribution of scores is illustrated in Figure 1.

Figure 1.

Box plot showing the distribution of the participants’ scores.

When comparing the means of the scores achieved after categorizing participants, Independent-Samples Kruskal-Wallis Test did not reveal a significant difference between the scores of students from different faculties (Test Statistic = 7.786, P-Vale = 0.051).

Mann-Whitney U Test revealed no statistically significant difference between males and females regarding scores in the final test (Mann-Whitney U = 341.5, Z = 0.822, P-Value = 0.411) with males scores just a little over females. The test also revealed no significant difference in scores of participants who previously attended first aid courses and those who did not (Mann-Whitney U = 125.5, Z = 0.425, P-Value = 0.461).

Spearman correlation revealed a moderate positive association between the academic year of the participant and the score achieved (r = 0.425, P-Value < 0.01).

To comprehensively analyze knowledge gaps and identify areas requiring reinforcement, we systematically analyzed the distribution of correct and incorrect answers for each question. As presented in Figure 2, the highest percentages of incorrect responses were for question 5 (“How is the shock state treated?”) and question 11 (“When the patient is poisoned as a result of a drug overdose, the patient is induced to vomit according to the principles of first aid?”). The full distribution of participant responses for each question is detailed in the same figure.

Figure 2.

Distribution of participants’ answers on each question.

Discussion

The Post-training assessment revealed strong knowledge retention of theoretical knowledge amongst participants, with no notable differences observed between medical and non-medical participants.

In conflict zones such as Syria, first aid training courses are critical for enhancing responses to traumatized patients. By equipping laypeople and community responders with essential skills, these courses enable life-preserving interventions at the point of injury, where professional medical care is often delayed or inaccessible. Core competencies include safe scene management, airway protection, bleeding control through manual compression and wound packing, environmental protection of the injured, and rapid casualty transport—skills that contribute directly to reducing preventable mortality and morbidity in high-risk, resource-constrained environments.^3,4

Such training also supports effective triage, allowing responders to prioritize care for those in greatest need during mass casualty events, which are common in conflicts.¹⁷ For select responders, advanced modules covering fracture immobilization and context-adapted transport logistics further improve trauma outcomes.³ Evidence from randomized trials and systematic reviews confirms that first aid training increases laypeople’s knowledge, practical skills, and self-efficacy, each crucial for effective prehospital trauma care.⁴

Within the Syrian context specifically, first aid training has demonstrated value in supporting task-shifting, conserving resources, and disseminating community education. This strengthens local capacity to manage surges in casualties and to operate effectively under conditions of siege or attack.^17,18 Overall, first aid training constitutes a cornerstone of trauma system preparedness and community resilience in conflict zones, enabling timely and appropriate care for the injured and thereby reducing mortality from otherwise survivable injuries.^3,4,17,18

Several factors influence the effectiveness of first aid training courses for university students, including academic background, curriculum structure, and delivery methods. Students in health-related fields (e.g., medicine, nursing, biological sciences) typically demonstrate higher baseline knowledge, greater skill acquisition, and a higher propensity to enroll in first aid courses compared to students from non-health disciplines. For instance, students in biological sciences show significantly greater odds of both participating in and benefiting from such training than their non-biological peers.^19,20 —the present analysis revealed no significant difference in scores between students from different universities. This finding may be attributable to the practical training component and the specific design of the curriculum.

Gender differences also influence training engagement and outcomes. Female students consistently exhibit greater motivation to attend first aid and CPR training, a higher willingness to respond in emergencies, and better retention of emergency contact information. In contrast, male students typically report higher self-confidence in their first aid abilities and demonstrate superior performance in specific CPR metrics, such as chest compression depth and fraction, which are critical for effective resuscitation.²¹ These general patterns align with the enrollment demographics of the current course, where females constituted the majority. However, the analysis indicated a significant, albeit slight, advantage in scores for male participants.

Furthermore, the analysis revealed no significant score differences between participants with prior first aid training and those without. This finding appears to contradict prior research, which indicates that repeated, structured training—particularly when following educational frameworks like the “Learn, See, Practice, Prove, Do, Maintain” model endorsed by the American Heart Association and American Red Cross—enhances skill acquisition and retention through spaced learning and deliberate practice.²² Meta-analyses and systematic reviews demonstrate that multiple training exposures lead to greater gains in knowledge, skills, and self-efficacy compared to single or no training.^4,23,24

However, direct evidence linking repeated training to improved patient outcomes or quality of care remains limited, underscoring the need for more rigorous longitudinal studies.^4,25,26 Despite this, the prevailing consensus supports the value of multiple, structured training sessions for optimizing university students’ understanding and competency. Although this study did not assess baseline knowledge, a prior study of the same population serves as a reference (discussed further in Limitations). In comparison, the present results show that three-quarters of participants scored above 12 points, with a median score of 13 and an interquartile range of 12 to 13. This contrasts with the earlier study, in which most participants obtained below-average to average scores, with only a small proportion achieving above-average results.¹⁰

The World Health Organization (WHO) has undertaken several initiatives to emphasize the importance of first aid, most notably through the development and promotion of its Community First Aid Responder Program. This initiative aims to address critical gaps in prehospital emergency care in low- and middle-income countries by training laypeople as first responders. By leveraging community engagement and local resources, the program enables immediate care for trauma and medical emergencies before professional assistance arrives.^27,28

Furthermore, the WHO has collaborated with organizations such as the International Committee of the Red Cross and the International Federation for Emergency Medicine to develop open-access basic emergency care courses. These collaborations extend the reach and impact of first aid education in resource-limited settings.²⁹ Collectively, these efforts form part of a broader strategy to build community capacity, reduce preventable morbidity and mortality, and establish the foundation for more advanced emergency medical systems in underserved populations.^27,28,30

Limitations

This study has several limitations. First, the sample size was relatively small. Many enrolled students could not attend the minimum of three sessions due to the start of the new academic semester and related travel obligations. Moreover, participation was voluntary; it would have been unethical to recruit participants solely to increase the sample size. An additional limitation is the absence of a baseline knowledge assessment before the course. To avoid recall bias and prevent students from disproportionately focusing on specific topics, the questions were not disclosed in advance. Instead, the study used the findings of Ataya et al.¹⁰ as a proxy baseline, as both studies sampled the same population. A detailed discussion of the pretesting effect and the rationale for employing a post-only design is provided in the supplement. Self-selection bias also emerged from the lack of randomized distribution of the students between the groups.

Strengths

This study is among the first to report on a structured first-aid curriculum in a conflict-affected setting such as Syria. In environments of ongoing instability, individuals face a heightened likelihood of emergencies where first-aid knowledge is critical for saving lives. Furthermore, the research highlights that evidence-based first-aid training might have a good impact on knowledge among college students across different academic disciplines. Ultimately, these findings contribute to strengthening community capacity for effective emergency response.

Conclusion

The research underscores the critical role of context-adapted first aid education in regions like Syria, where fragmented health systems and limited access to professional care elevate the importance of community-level responders. By equipping laypersons with essential knowledge, such initiatives contribute to building local resilience, reducing preventable mortality, and strengthening the overall chain of survival in humanitarian crises.

Future longitudinal research is needed to assess skill retention, practical application, and the direct impact of such training on patient outcomes. Nonetheless, integrating foundational first aid education into broader community health strategies remains a vital step toward mitigating the profound health consequences of armed conflict. Moreover, it is important to include larger study samples in the future research to ensure getting a higher statistical power.

Supplemental material

Supplemental material - First aid training in conflict zones: An interventional training study and a post-training knowledge assessment

Supplemental material for First aid training in conflict zones: An interventional training study and a post-training knowledge assessment by Kinan Jafar, Rami Janoud, Ahmed Sheikh Sobeh, Rawan Al-Deeb and Omran Janoud in Sage Open Medicine.

Footnotes

Acknowledgements

The authors would like to sincerely thank Tabeebak Organization, especially the instructors who delivered the lectures during the first aid course, for their dedication and expertise. We particularly thank Dr. Median Khwis and Coach Amer Alsaady for their participation as lecturers in the course. We are also deeply grateful to Medical Research Empowerment International team for their invaluable assistance in ensuring the high quality and successful publication of this paper. Additionally, we extend our appreciation to both the Platform Center, where the course was held, and the Student Assembly in Suwayda for their excellent collaboration throughout this project. Their combined support has been essential to our academic progress and the dissemination of important medical knowledge.

ORCID iD

Rawan Al-Deeb

Ethical considerations

Platform Center Executive approved the study. An ethical approval for conducting the study was obtained from Health Directorate in Swaida affiliated with Ministry of Health (ID number 273).

Consent for publication

Written informed consent for publishing anonymous data was obtained from all participants. The participants were informed about their right to withdraw from the study at any point without any penalty.

Author Contributions

(O.J. & K.J.) outlined the methodology, organized the sessions, gave 3 lectures (2 lectures by O.J. and 1 lecture by K.J.) out of 5 within the course and contributed to manuscript writing and editing. (O.J.) performed the statistical analysis. (R.J.) Collected and uploaded the data, responsible for data curation and contributed to to manuscript writing and editing. (R.A.D. and A.S.S.) contributed to manuscript writing and editing. All authors reviewed and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.*

Supplemental material

Supplemental material for this article is available online

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Supplementary Material

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