Efficacy of a lay first responder program: Results from a pilot cohort in Uganda

Road traffic injuries (RTIs) are a leading contributor to the disproportionate global injury burden in low- and middle-income countries (LMICs). Emergency medical services (EMS) could address up to 45% of RTI-related mortality, yet 91.3% of the African population lacks EMS access. With WHO recommending lay first responder (LFR) training, evaluating longitudinal applications of LFR models is critical for sustainable prehospital care development. This study assessed the efficacy of a pilot LFR program in Mukono, Uganda, over six months, focusing on knowledge retention, training prioritization, and financial feasibility for scale-up. A longitudinal cohort of 225 motorcycle taxi drivers completed a 5.5-hour modular first aid course in June 2022, delivered in English and Luganda using a training-of-trainers model. In January 2023, 133 participants (59.1%) attended a refresher session. Knowledge was assessed pre- and post-training at both timepoints with a validated 25-question test. Wilcoxon tests examined knowledge acquisition and decay and a generalized linear mixed-effects model (GLMM) evaluated demographic predictors (time, education, age, income, dependents, prior experience). Real-world interventions were tracked via incident reports over six months, and costs were recorded to estimate scalability. Participants were all male, median age 30 years (IQR:25,35), with median five years of transportation provider experience (IQR:3,8). GLMM analysis indicated significant global effects for time, income, number of dependents, age, and education; however, pairwise comparisons of estimated marginal means revealed clear differences only for income (lowest vs. highest) and dependents (0 vs. 1–2 or 3–5). Age, education, and prior experience did not show significant pairwise differences. Knowledge scores improved significantly after initial training (pre-test: 33.4%, post-test: 62.6%; PPDI: 29.2%, p<0.001) and refresher training (pre-test: 46.3%, post-test: 76.4%; PPDI: 30.1%, p<0.001). Significant decay occurred between initial post-test and refresher pre-test (−16.3%, p<0.001), particularly in airway management. Refresher post-test scores exceeded initial post-test scores by 13.9% (p<0.001), indicating strong reinforcement. Forty-four responders (19.6%) submitted 91 incident reports. RTIs comprised 61.5% of cases, with 72.5% transported by motorcycle. Lower extremity injuries were most common (51.6%), and fracture splinting (37.4%) and patient extrication (36.3%) were the most frequent interventions. Program costs totaled $2,888.31 USD ($12.84 per trainee), including first aid kits, venue, food, printing, and trainer stipends. LFR participants demonstrate significant knowledge acquisition and decay, underscoring the need for regular refresher training, particularly in airway and fracture management. Knowledge retention is influenced by contextual factors such as income and family responsibilities, while prior experience, education, and age appear less impactful. LFR programs are feasible, cost-effective, and have the potential to reduce injury-related morbidity and mortality, providing a scalable model to strengthen prehospital care systems in LMICs. • LFR training significantly improves knowledge, but decay occurs by six months. • Refresher courses restore knowledge, especially in airway and fracture care. • Income and number of dependents influence performance, suggesting context impacts training equity. • Small active responder pool shows "super-responder" phenomenon in incident reporting. • LFR programs are feasible, cost-effective, and support EMS in LMICs like Uganda.