The results of our study indicate overall staff knowledge of first aid to be lacking, evidenced by the low but visible frequency of incorrect responses to common illnesses and injuries. The American Academy of Pediatrics has set 80% as the passing level in its written knowledge exam of pediatric first aid training for caregivers and teachers. According to that criterion, only 3.7% of the surveyed teachers had an adequate knowledge of first aid. Questions related to splinters (incorrect rate: 61.4%), nosebleeds (59.4%), Insect stings (56.1%), fainting (41.2%), reducing infection by flushing the injured area with running water (42.9%), heatstroke (42.1%), bites to the tongue (38.8%), inhaled poison (27.6%), and chemical injury to the eye (23.0%) were most often answered incorrectly. With regard to a child swallowing poison, if the victim vomits, the insulting substance may cause more damage as it passes through the esophagus a second time. Induction of emesis is wrong and harmful [20
], but many of the study participants thought it appropriate. In cases of poisoning, 33% of the staff members in our study would not take both the child and the poison bottle directly to the hospital. In the present study, the rate of correct answers to questions about convulsive seizures was lowest; only 16.5% of responders would act to first protect the head. Similarly, Dantas in Brazil demonstrated that teachers’ knowledge about the clinical characteristics and initial procedures to attend a person during a seizure was also unsatisfactory [21
]. Fewer than 13% of them knew to protect the head. Childhood encounters with bees, wasps, yellow jackets, hornets, and fire ants can be a natural consequence of children's curiosity and exploration. In most cases, insect stings do not require medical attention. However, a severe allergic reaction to an insect sting can occur very quickly, without warning, and can be life-threatening. Insect bites, especially bee stings, can be fatal in short periods of time if the injured person has an extreme sensitivity and is not given first aid immediately [17
]. Mild allergic reactions include hives and swelling, but death can occur from edema of the respiratory system [22
]. This study determined that 43.9% employees did not know to remove bee stingers immediately, and only 56.1% of employees in the study knew to move the child to a safe area and remove any stingers. With regard to heatstroke, 42.1% of responders knew to cool the child immediately and call EMS. Heatstroke can develop suddenly, and an infant or child with heatstroke will have a body temperature of 106 °F or higher. Once the sweat glands' ability to produce sweat is exhausted, the skin may be dry and hot. If the body temperature does not go down, brain damage and death can occur [17
]. In cases of choking and coughing, the number of incorrect responses was disturbing (30.1%). The course of action for dealing with a casualty who is choking but also breathing is to allow him or her to continue coughing, because they still have a clear airway [22
]. An infant or child with a partially blocked airway continues to breathe, but will usually be coughing. Coughing is the body's way of removing what feels like a foreign object. When there is an object in the airway, forceful coughing is more effective than anything anyone else can do to get the object to move up and out of airway [17
]. But most responders indicated that they would clap the child's back. Prior studies regarding the knowledge of first aid knowledge among preschool staffs have been scarce. In the U.S., Gagliardi et al. has indicated that most teachers are deficient in knowledge of emergency care and basic life support modalities [25
]. A study conducted in Turkey evaluating the first aid knowledge and attitudes of 312 primary school teachers showed that most of the teachers lacked accurate knowledge about first aid [22
]. Physical education teachers at schools in Ireland also showed poor knowledge of how to treat children during emergencies [23
Injury is a common cause of morbidity and mortality in children. Prompt, appropriate treatment can help decrease this morbidity and mortality. Because children spend the majority of their day in school, teachers should be proficient in basic first-aid skills. In this study, only 30.6% of the study participants had ever received first-aid training before; however, they only had been trained in cardiopulmonary resuscitation and not in the treatment of common children’s injuries. The results of a study carried out by Gagliardi on the extent of training and emergency care knowledge of public school teachers in the U.S. indicated that one-third of surveyed teachers had no specific training in first aid, and 40% had never been trained in cardiopulmonary resuscitation [25
]. This is also in keeping with other studies from North America, which found that 30% of teachers had no specific training in first aid, and 40% had never been trained in CPR [26
]. One U.S. study found that only 75% of child care center administrators surveyed reported that first aid training was required for their staff, and only 15% of child care centers serving children with special care needs required its staff to be CPR-certified [3
]. In the U.S., approximately half of all child care centers do not have specific written procedures for urgent medical emergencies, such as severe bleeding, unresponsiveness, poisoning, shock, heart or circulation failure, seizures, head injuries, anaphylaxis, or allergic reactions [3
]. The American Academy of Pediatrics recommends that at least one staff member who has successfully completed training in pediatric first aid be in attendance at all times and in all places where children are present. Injury studies conducted at childcare centers have demonstrated that the most common injuries are minor and that severe injuries requiring medical attention comprise only 1% to 7% of the total injuries [28
]. The most common injuries in childcare centers reported in the literature include fractures, lacerations, contusions, and dental injuries [30
]. One study reported that 84% of injuries occurring in the child care settings required first aid treatment [11
]. More effort should be made to increase first aid and CPR training for childcare center staff members, because many emergencies can be managed with these lifesaving skills. Our results clearly demonstrate there are grave deficiencies in the provision of first aid for children among preschool staffs in Shanghai. The lack of formal and effective emergency care training in teacher preparation programs coupled with a lack of continuing education requirements is one possible explanation for these results [25
]. Using data from the present study, a comprehensive campaign should be planned for Shanghai.
The current findings show that healthcare providers scored very high on the questionnaire, which is likely related to the fact that healthcare providers by definition have pre-existing medical knowledge. Younger employees also scored higher, which may be due to younger employees frequently possessing higher educational levels and having already been exposed to newer knowledge regarding first aid. Performing proper first aid is a fairly complex set of tasks. Knowledge is necessary but not sufficient. While the attitudes towards giving first aid is assumed to be of direct importance to performance in first-aid situations, the attitudes towards learning first aid may be of greater, if indirect importance [19
]. Our survey showed that most teachers’ attitudes towards giving or learning first aid were positive, but it remains necessary to increase their actual first aid knowledge and skills. Improvement in child care centers' preparedness to respond to emergencies and disasters should include maintaining the immediate availability of potentially life-saving medications and ensuring that all child care center employees are trained in first aid and, where appropriate, CPR [3
]. Pediatricians should take an active role in training first responders in pediatric assessment and CPR, and assist preschools in developing disaster plans. Teaching first aid offers an opportunity to educate childcare providers and teachers about risk factors for specific injuries. Identification and actions taken to reduce risk delivered alongside first aid training may reduce the overall rate of child injury.
This study has several limitations. The primary limitation is that the investigation of 1067 employees in Shanghai is not representative of other parts of China, largely because there are significant socio-economic disparities between China’s western and eastern provinces; Shanghai is one of the most developed cities in China. Similar studies conducted throughout the country are necessary. Our study was also limited in that it did not evaluate staff members' skills in implementing first aid. This was because most of our participants had none. First aid knowledge alone does not ensure proper conduct during an emergency.