Introduction
Prehospital care is emergency medical care provided to patients prior to their arrival at the hospital after Emergency Medical Services have been activated. Reference Wilson, Habig, Wright, Hughes, Davies and Imray1 For severely ill or injured patients, acting quickly in the prehospital period is crucial with decisions and interventions greatly affecting outcomes. Reference Wilson, Habig, Wright, Hughes, Davies and Imray1,Reference Nutbeam and Boylan2
Evidence showed that a health care provider who doesn’t have adequate knowledge about prehospital emergency care results in dissatisfaction with the care given to the client. Reference Larsson, Strömberg, Rogmark and Nilsdotter3 While a health professional or care provider having good knowledge, attitude, practice, or skills in prehospital emergency management leads to proper handover of the patient to the emergency department, which has a great role in decreasing the morbidity and mortality of the individual, increasing health-related quality of life, and having a significant role in increasing the life expectancy of the community. Reference Sanjuan-Quiles, del Pilar Hernández-Ramón, Juliá-Sanchis, García-Aracil, Castejón-de la Encina and Perpiñá-Galvañ4,Reference Plummer and Boyle5
According to the World Health Organization (WHO; Geneva, Switzerland), road traffic accidents (RTAs) are currently the eighth leading cause of death globally and the tenth leading cause in sub-Saharan Africa (SSA), resulting in 1.402 million deaths per year world-wide in 2016, and from these, 284,000 were in SSA. 6 In Africa, the challenge is even more pressing, which currently shows RTA deaths could rise by 30% to 1.85 million per year by 2030, making it the world’s seventh biggest cause of death. In Ethiopia, the prevalence of RTAs is still high despite little attention being given. Reference Tsegaye, Abdella, Ahmed, Tadesse and Bartolomeos7 Providing efficient and effective post-crash care and prehospital treatment for injuries, hemorrhage, and other medical and obstetrical emergencies timely by paramedics has a great role in reducing morbidity and mortality of the patients. Reference Murad, Larsen and Husum8,Reference Bedard, Mata and Dymond9 Therefore, this study was intended to assess the knowledge, attitude, and associated factors of emergency healthcare providers (EHCPs) towards prehospital care in Addis Ababa, Ethiopia. To the best of the investigator’s knowledge, there are no data available on the knowledge and attitude of EHCPs towards prehospital care and associated factors in Ethiopia.
Assessing EHCPs’ knowledge, attitude, and associated prehospital care factors will have a significant impact on future plans to improve EHCPs’ knowledge and the quality of prehospital care. It can also help any interested researchers develop baseline findings for further research in this area.
Methods
Study Design, Setting, and Period
An institutional-based cross-sectional study was conducted among prehospital EHCPs from November 20 through December 4, 2022.
This study was conducted in the capital city of Ethiopia, Addis Ababa. In Addis Abeba, there are one government and three private prehospital care centers, with approximately 192 nurses working in these facilities. For this study, Addis Ababa City Fire and Emergency Prevention Rescue Agency (AAFEPRA), Nordic Medical Center (NMC), and TEBITA Ambulance (Pre-Hospital Emergency Medical Service PLC) were selected as the study areas.
Ethiopia’s AAFEPRA was established in 1934 to prevent and control fire and related accidents. In 2008, it started to provide prehospital care to the community. It has more than 160 emergency care providers and nine stations, of which the main branch is found in the Arada sub-city.
The TEBITA Ambulance service is Ethiopia’s first commercial provider of prehospital Emergency Medical Services. It has a total of 17 emergency medical technicians (EMTs) and is located in Addis Ababa.
The NMC, also located in Addis Ababa, is run by Norwegians and is staffed by highly experienced international and Ethiopian medical professionals. They deliver high-quality medical services 24/7 and are the preferred medical provider for a number of international organizations, embassies, and health insurance companies. The NMC offers emergency and critical care medical services throughout Ethiopia. It has a total of ten emergency and critical care nurses (ECCNs) working in the ambulance. This study is reported in line with the STROCCS checklist (available as Supplementary Material, online only). Reference Agha, Abdall-Razak, Crossley, Dowlut, Iosifidis, Mathew and STROCSS10
Source Population
The source populations were all prehospital EHCPs in Addis Ababa, Ethiopia.
Study Population
The study population included all prehospital EHCPs (ECCNs and EMTs) in AAFEPRA, NMC, and TEBITA Ambulance who were available during the data collection period.
Eligibility Criteria
All prehospital emergency care provider ECCNs and EMTs who had more than six months of work experience and were on duty during data collection period were included.
Sample Size and Sampling Technique
A single population proportion formula was used (by taking Z = 1.96, P = 50% since there is no similar study conducted in Ethiopia, and d = 0.05) to get the minimum sample size n 0 of 384. Since there was a population N of 192, a finite population correction formula was used to get a sample size n of 128. Adding a 10% non-response rate gave a final sample size n of 141.
Using proportional allocation to the size of each individual institution, a sample of 121, seven, and 12 participants were taken from AAFEPRA, NMC, and TEBITA Ambulance, respectively. Finally, a simple random sampling method was utilized in each institution to get the allocated numbers of EHCPs.
Knowledge and attitude of EHCPs towards prehospital care were the dependent variables, whereas age, sex, marital status, occupation, training, working unit, educational level, work experience, availability of protocols and guidelines, and equipment availability were considered as the independent variables.
Data Collection Tools and Procedures
Data were collected using a self-administered structured questionnaire, which has three parts. The first part is the demographic data of the participants. The second part is designed for the knowledge assessment of the EHCPs. The third part is used to assess the attitude of EHCPs, which is adapted and modified from similar studies. Reference Nshutiyukuri, Bhengu and Gishoma11,Reference Mothibi, Jama and Adefuye12
After the planned study was reviewed and approved by the Institutional Review Board of St. Paul’s Hospital Millennium Medical College (SPHMMC; Addis Ababa, Ethiopia), approval to conduct the study was obtained. Official permission to conduct the study was also obtained from the institutions. Participants were approached, and the purpose of the study was explained to them before requesting their consent to participate in the study. The questionnaire was given to those who consented to participate in the study. Data were collected by three diploma nurses, one degree nurse supervisor, and one facilitator from each center. Data collection took place from November 20 through December 4, 2022.
Operational Definitions
For the purpose of this study, the following definitions were used:
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Good Knowledge: A knowledge score above or equal to the mean score was categorized as having good knowledge.
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Poor Knowledge: A knowledge score below the mean score was categorized as having poor knowledge.
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Favorable Attitude: An attitude score above or equal to the mean score was categorized as having favorable attitude.
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Unfavorable Attitude: An attitude score less than the mean value was considered as having unfavorable attitude.
Data Analysis and Presentation
The collected data were checked for their completeness, consistency, and accuracy before analysis. Data were checked, cleared, and entered into SPSS version 26 (IBM Corporation; Armonk, New York USA); then frequencies, means, and analyses were performed to obtain a significant association at the bivariate level by P <.25, followed by multivariate logistic regression at a P value of <.05. Finally, the results of the study were processed and analyzed using descriptive statistics like percentage, frequency, and association. Text, tables, and charts were used to present the findings.
Data Quality Management
The data collectors were trained for two days on how to ask for consent from the study group and fill out the questionnaire. During the data collection period, the supervisor provided supervision and support to the data collector as needed. The questionnaire was checked for completeness and consistency by the principal researcher. Before the actual data collection, a pre-test was done on 10% of the total sample size at the prehospital service center located in the study area (Nebiela Ambulance) to check the completeness, consistency, and quality of the material content. After pre-testing the questionnaire, Cronbach’s alpha was calculated by using SPSS window version 26 to test the internal consistency (reliability) of the item, and Cronbach’s alpha was 0.81.
Ethical Approval
Ethical permission was obtained from the SPHMMC’s Institutional Review Board. The permission was obtained from AAFEPRA, NMC, and TEBITA Ambulance. Informed consent was secured from all study participants after telling them the aim, benefits, and risks of participating in the study. The anonymity of the study subjects’ information was kept confidential.
Results
Socio-Demographic Characteristics of the Respondents
One hundred thirty-five (135) study participants were included in this study, with a response rate of 95.7%. More than one-half of the study participants, 76 (56.3%), were females. The mean age of the respondents was 29.2 years (SD = 4.86). Ninety-six (96; 71.1%) were aged between 26 and 35 years. The majority of study participants (109; 80.7%) were fire workers. Regarding the educational background, 96 (71.1%) of the study participants were bachelor degree holders, and 65 (48.1%) of the study participants had six to ten years of work experience (Table 1).
Table 1. Frequency Distribution of Socio-Demographic Characteristics of EHCPs in the Three Selected Prehospital Emergency Medical Service Institutions in Addis Ababa, Ethiopia, 2022 (n = 135)
Abbreviations: AAFEPRA, Addis Ababa City Fire and Emergency Prevention Rescue Agency; EHCP, Emergency Health Care Provider.
Knowledge of EHCPs towards Prehospital Care
The overall knowledge score was calculated by tallying the individual response rates and calculating the mean to categorize the participants’ knowledge as good or poor. Based on this, 58.5% of the EHCPs had good knowledge and 41.5% had poor knowledge about prehospital care (Figure 1).
Figure 1. Pie Chart Illustrating Knowledge of Emergency Health Care Providers (EHCPs) towards Prehospital Care Working in the Three Selected Prehospital Emergency Medical Service Institutions in Addis Ababa, Ethiopia, 2022 (n = 135).
Almost three-quarters (74.8%) of study participants said they had learned more about prehospital care on the job. The majority of study participants (93.3%) said they knew about Basic Life Support (Table 2).
Table 2. Knowledge of EHCPs towards Prehospital Care in the Three Selected Prehospital Emergency Medical Service Institutions in Addis Ababa, Ethiopia, 2022 (n = 135)
Abbreviation: EHCP, Emergency Health Care Provider.
Attitude of EHCPs Regarding Prehospital Care
The overall attitude score was calculated by counting the individual response rate and calculating the mean to classify their attitude as favorable or unfavorable. Based on this, 51 (37.8%) of the EHCPs had an unfavorable attitude and 84 (62.2%) had a favorable attitude towards prehospital care (Figure 2).
Figure 2. Bar Chart Showing the Attitude of Emergency Health Care Providers (EHCPs) towards Prehospital Care Working in the Three Selected Prehospital Emergency Medical Service Institutions in Addis Ababa, Ethiopia, 2022 (n = 135).
More than one-half of the study participants (94; 69.4%) strongly agreed that giving prehospital care to needy people is fair, and 97 (71.9%) strongly agreed that learning prehospital care was useful for them. Almost three-quarters of the respondents (74.8%) strongly agreed that prehospital care training was mandatory (Table 3).
Table 3. Attitude of EHCPs towards Prehospital Care in the Three Selected Prehospital Emergency Medical Service Institutions in Addis Ababa, Ethiopia, 2022 (n = 135)
Abbreviation: EHCP, Emergency Health Care Provider.
Factors Associated with Knowledge of EHCPs towards Prehospital Care
In binary logistic regression, it was shown that age group, sex, profession, service year, educational status, and training were significantly associated with the knowledge of EHCPs towards prehospital care at a P value <.25. Furthermore, variables with a P value <.25 that were significantly associated with EHCPs’ knowledge of prehospital care were candidates for multivariable logistic regression analysis (Table 4).
Table 4. Multiple Logistic Regression Analysis of Factors Associated with EHCPs’ Knowledge towards Prehospital Care in the Three Selected Prehospital Emergency Medical Service Institutions, Addis Ababa, Ethiopia, 2022 (n = 135)
Abbreviation: EHCP, Emergency Health Care Provider.
a Significant association.
A multivariable logistic regression model showed that profession, educational status, and training were significantly associated with the knowledge of EHCPs to provide prehospital care with a P value <.05 and a 95% CI. The respondents’ profession was significantly associated with EHCPs’ knowledge of prehospital care. When compared to nurses, EMTs were three-times more likely (AOR = 3.2; 95% CI, 1.03 - 7.65) to have good knowledge of prehospital care. Respondent educational status was significantly associated with the EHCPs’ knowledge of prehospital care. The EHCPs with a master’s degree were 17% (AOR = 1.17; 95% CI, 1.08 - 4.93) more likely to be knowledgeable about prehospital care than those with a diploma. Having training was significantly related to health care providers’ knowledge of prehospital care. When compared to their counterparts, EHCPs who received training were twice as likely (AOR = 2.25; 95% CI, 1.33 - 4.52) to have good knowledge of prehospital care (Table 4).
Factors Associated with Attitude of EHCPs towards Prehospital Care
In a binary logistic regression, it was shown that the sex of the respondents, working hours, service year, training, and knowledge of health care providers were significantly associated with their attitude towards prehospital care at a P value <.25. In addition, those variables significantly associated with the attitude of EHCPs towards prehospital care at a P value <.25 were candidates for multivariable logistic regression analysis (Table 5).
Table 5. Multiple Logistic Regression Analysis of Factors Associated with EHCPs’ Attitude towards Prehospital Care in the Three Selected Prehospital Emergency Medical Service Institutions, Addis Ababa, Ethiopia, 2022 (n = 135)
Abbreviation: EHCP, Emergency Health Care Provider.
a significant association.
A multivariable logistic regression model revealed that respondent knowledge and receiving training were significantly associated with EHCPs’ attitudes towards prehospital care, with a P value <.05 and 95% CI (Table 5).
Respondent knowledge was significantly related to health care providers’ attitudes towards prehospital care. When compared to EHCPs with poor knowledge, those with good knowledge had a 36% (AOR = 1.36; 95% CI, 1.05 - 2.32) higher likelihood of having a favorable attitude towards prehospital care (Table 5).
Having training was significantly associated with the attitude of health care providers towards prehospital care. The EHCPs who got training were three-times (AOR = 3.2; 95% CI, 1.24 - 7.83) more likely to have a favorable attitude towards prehospital care as compared to their counterparts (Table 5).
Discussion
The findings of this study showed that 58.5% of the EHCPs had good knowledge regarding prehospital emergency medical care. This is lower than a study done in India, which revealed a large portion the study participants (80%) had adequate knowledge, 13% had moderate knowledge, and eight percent had inadequate knowledge. 13
In this study, 37.8% of the EHCPs had unfavorable attitude and 62.2% had favorable attitude towards prehospital care. This is almost similar to the study finding from Rwanda, which indicated that 39.3% of the nurses had favorable attitude towards the emergency care of RTA victims. Reference Nshutiyukuri, Bhengu and Gishoma11 In contrast, this study is lower than a study done in Indonesia that showed that 84.6% of participants had positive attitude and the remaining 15.5% had un favorable attitude. 13 This discrepancy might be due to the difference in the study area, study design, and geographical location.
The respondents’ profession was significantly related to EHCPs knowledge of prehospital care. Emergency medical technicians were three-times (AOR = 3.2; 95% CI, 1.03 - 7.65) more likely to have good knowledge as compared to the nurses providing prehospital care.
Another variable, the respondents’ educational status, was found to be significantly associated with EHCPs’ knowledge of prehospital care. The EHCPs with a master’s degree had a 17% (AOR = 1.17; 95% CI, 1.08 - 4.93) higher likelihood of having good knowledge about prehospital care than those with a diploma. This is similar to the result from Tehran: no significant difference was observed between knowledge and any demographic characteristic (P = .05) where education level was related to attitudes towards prehospital care. Reference Nshutiyukuri, Bhengu and Gishoma11,Reference Rajashekar, Gowda and Anthony14
Having training was significantly associated with health care providers’ knowledge of prehospital care. When compared to their counterparts, the EHCPs who received training were twice as likely (AOR = 2.25; 95% CI, 1.33 - 4.52) to have good knowledge about prehospital care. This is similar to a study done in Indonesia, which showed that training had a significant influence on knowledge, attitude, and practice scores for prehospital care. Reference Shakeri, Fallahi-Khoshknab, Khankeh, Hosseini and Heidari15
Respondent knowledge was significantly associated with EHCPs’ attitudes towards prehospital care. When compared to EHCP with poor knowledge, those with good knowledge were 36% more likely (AOR = 1.36; 95% CI, 1.05 - 2.32) to have favorable attitude towards prehospital care. Previous training was significantly associated with the attitude of EHCPs towards prehospital care. When compared to their counterparts, the EHCPs who received training were three-times more likely to have a favorable attitude towards prehospital care (AOR = 3.2; 95% CI, 1.24 - 7.83).
Limitations
This study was novel in Ethiopia and can serve as a starting point for future researchers. The limitations of this study were the lack of domestic works of literature done in the related study area, and the probable lack of external validity of the findings. In addition to this, this study did not include the level of practice of EHCPs in prehospital care.
Conclusion
The majority of the EHCPs had good knowledge about prehospital care, and more than one-half of them had a favorable attitude towards prehospital care. Profession, educational status, and training were significantly associated with the knowledge of EHCPs to provide prehospital care. Knowledge of the respondent and having training were significantly associated with the attitude of EHCPs towards prehospital care. In-service training regarding emergency health conditions and the time needed to care for the patient is important for better prehospital emergency care. Enhancing individual-level education and work exposure in emergency care enables better performance in prehospital emergency care. Further studies should also be conducted in a multi-center approach to address the problem in a broader context.
Conflicts of interest/funding
This research was funded for a total of USD$530 by St. Paul’s Hospital Millennium Medical College (Addis Ababa, Ethiopia). The authors declare that there are no conflicts of interest.
Author Contribution
All authors contributed equally on the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the article or revising data content, and approval of the final the version.
Acknowledgements
The authors would like to acknowledge St. Paul’s Hospital Millennium Medical College Institutional Review Board for providing ethical clearance. Special thanks also goes to Addis Ababa Fire and Emergency Prevention and Rescue Commission, the Ethiopian Red Cross Society Addis Ababa Branch, and TEBITA Ambulance for their cooperation during data collection.
Supplementary Materials
To view supplementary material for this article, please visit https://doi.org/10.1017/S1049023X23005915
