Community First Aid Training

Publication Date: 2022

Executive Summary

Overview

This study examined the effectiveness of Disaster Response Advanced First Aid (DRAFA) training in preparing community members to respond to disaster-caused medical emergencies prior to the arrival of organized help, and thus enhancing community resilience. DRAFA, which provides 24 hours of training over several days, is designed for community members and first responders with no or limited medical training. The DRAFA curriculum covers preparation, assessment, and treatment of common disaster-caused illnesses and injuries. Two classes of DRAFA were delivered to a total of 38 community members from the Commonwealth of the Northern Mariana Islands (CNMI). Disaster-related first aid knowledge, skills, self-efficacy, and willingness to respond were tested.

Research Questions

The study asked three main questions:

1. Were knowledge and skills of disaster-focused first aid significantly improved by taking DRAFA?
2. Was self-efficacy of knowledge and skills of disaster-focused first aid significantly improved by taking DRAFA?
3. Was willingness to respond to disaster-caused medical emergencies significantly improved by taking DRAFA?

Research Design

The University of Colorado School of Medicine taught two DRAFA classes, serving a total of 38 participants, on Saipan, part of the CNMI. Participants were firefighters, police officers, Homeland Security personnel, nursing students, and general community members.

Participants were pre-tested regarding knowledge, self-efficacy, and willingness to help and were post-tested on the same measures at the conclusion of their class. Using a skills check-list, participant skills were evaluated during skill sessions. Skills were practiced until competency was demonstrated. Skills were also evaluated during scenarios.

Findings

Results showed generally strong improvements for those taking DRAFA, including in disaster-related first aid skills, self-efficacy, willingness to respond, and especially knowledge.

Strong and highly significant improvements in knowledge were found in both classes. Self-efficacy showed moderate and significant increases in the two classes. Willingness to act or respond was weakly and significantly found to increase in one class, but not in the other.

Public Health Implications

As described in the literature review of this report, evidence supports training community members in emergency medical response in disasters due to inherent delays in organized emergency medical system (EMS) response. This study demonstrated the effectiveness of DRAFA in terms of preparing community members to respond to disaster-caused medical emergencies, prior to the arrival of organized or official responses, thus enhancing community resilience.

Research on community resilience has conceptualized it as the ability of a community to prepare for, respond to, and recover from adverse events. DRAFA training enhances resilience by preparing community members and first responders to deliver first aid during and immediately after disasters, helping communities to absorb impacts and more quickly and effectively recover.

DRAFA training adds to resilience through its robustness, redundancy, and rapidity. By working with, and training individuals from multiple organizations, DRAFA develops and strengthens networks and relationships, increasing social capital. Finally, DRAFA builds resilience by reducing the need for acute health system surge capacity.

Much of the literature about resilience and disasters is academic and abstract. DRAFA provides a public health tool to not just theorize, but to implement, test, and ultimately to make a real-world difference in the lives of disaster survivors and their communities.

Beyond resilience, DRAFA positively impacts public health by building infrastructure for public health, communicating to educate, strengthening communities and partnerships, creating and implementing plans, and building a skilled workforce.

This study also has public health implications based on the setting’s sociodemographic characteristics. As an isolated island chain, facing significant economic struggles, the CNMI provides a model for similar U.S. Territories and small island nations, in terms of social vulnerabilities. Shown to be effective in the Northern Marianas, DRAFA could also be valuable in other challenged locations.

Introduction

During and immediately after a disaster, medical help from organized emergency medical system (EMS) is inevitably delayed. This means local community members’ first aid response is critical (Fatoni et al., 2022¹; Kano et al., 2005²; Khorram-Manesh et al., 2020³; Paciarotti & Cesaroni, 2020⁴; Roces, et al., 1992⁵; Schultz et al., 1996⁶; Whittaker et al., 2015⁷). However, there is limited research regarding community first aid training and skills and the impact on disaster outcomes (Fatoni et al., 2022; Kano et al., 2005). This study benefits public health practices by beginning to fill the gap in the literature through examining the efficacy of training community members in Disaster Response Advanced First Aid (DRAFA) (see Appendix A for a list of course topics). The study also generated benefits beyond the research by enhancing community resilience, social capital, and sustainability through training dozens of local community members, from multiple agencies, to respond to disaster-caused medical emergencies and through developing and strengthening inter-agency networking.

DRAFA is a unique course specifically designed to teach community members and non-medical first responders to prepare for and respond to disaster-caused medical emergencies prior to the arrival of EMS or other organized help. DRAFA was originally designed in response to the needs of coastal Oregon communities, which face significant natural hazard risk from the Cascadia fault and the potential for earthquakes and tsunamis. The course was developed and piloted in 2016 by the University of Colorado School of Medicine, from adapted wilderness medicine curricula.

Literature Review

When disasters strike, organized emergency medical response is generally delayed. Thus, much of the initial and critical first aid is, by default, conducted by community members (Kano et al., 2005; Khorram-Manesh et al., 2020; Paciarotti & Cesaroni, 2020; Roces et al., 1992; Schultz et al., 1996; Whittaker, et al., 2015). Despite this common observation, there is little in the disaster literature regarding training community members in first aid. Literatures reviewed in this study included those related to community first aid training and disaster preparedness, community resilience, small island vulnerabilities, disaster-related self-efficacy and willingness to help, and issues related specifically to the study site, the Commonwealth of the Northern Mariana Islands (CNMI).

Community First Aid Training as Related to Disaster Preparedness

While the importance of community layperson response to disaster-caused medical emergencies is commonly accepted, there has been very little attention paid to the training of community members to respond. DRAFA is an example of a community first aid training, in this case with the specific goal of preparing for and responding to disaster-caused medical emergencies.

In a disaster, community members are the first and sometimes the sole source of initial help (Whittaker et al., 2015). As Wulff et al.,⁸ (2015, p. 367) pointed out “the most likely person to provide immediate assistance in an emergency will be a friend, coworker, family member, or passerby rather than a professional first responder.” Studies have shown that first aid training programs can improve skills for community members (Smith et al., 2016⁹; Van de Velde et al., 2009¹⁰), but the disaster literature has largely ignored how such trainings might impact community resilience in responding to a disaster.

Community Resilience

Increasingly, community resilience building is seen as a way to strengthen communities, reducing the negative impacts of disasters (Chandra et al. 2011¹¹; Mayer, 2019¹²). Wulff and colleagues (2015) noted:

[W]hether a community is in the path of a natural disaster, the target of an act of terror, or simply striving to meet the demands of increasingly dense urban populations, a community resilience paradigm can help communities and individuals not just to mitigate damage and heal, but to thrive. (p. 361)

Resilience in terms of the disaster literature is the capacity of a community to “return to some equilibrium state after a crisis through processes of both resistance and adaptation” (Mayer, 2019, p. 167). According to the National Strategy for Public Health and Medical Preparedness issued by the White House¹³ in 2007:

Where local civic leaders, citizens, and families are educated regarding threats and are empowered to mitigate their own risk, where they are practiced in responding to events, where they have social networks to fall back upon, and where they have familiarity with local public health and medical systems, there will be community resilience that will significantly attenuate the requirement for additional assistance. (para. 20)

Beyond Resilience

The concept of resilience, though widely adopted across disciplines, has also seen its share of criticism (Mahdiani & Ungar, 2021¹⁴). Most relevant to the disaster literature, resilience has been critiqued as an emphasis on returning to and perpetuating the possibilities of dysfunctional norms, rather than strengthening and improving community wellness (Kelman et al., 2015¹⁵, p. 22). Returning to the pre-disaster “normal,” may mean returning to “poor development, poverty, vulnerability, and disaster, not building a better future.” In this sense, training community members in disaster first aid skills goes beyond merely helping a community return to how things were before a disaster; rather, it improves the community by teaching a whole new set of practical skills, applicable to many situations. The disaster first aid skills are transferable to hazards from “multiple exposures” such as poverty, violent crime, local traffic accidents, etc. (Kelman et al., 2015). The training further strengthens society through day-to-day better trained community emergency medical response, as well as by building networks and social capital.

Community First Aid Training as a Way to Enhance Resilience

Unfortunately, while community resilience has been shown to significantly strengthen communities, investments are still insufficient. According to Wulff et al., (2015) community resilience-building has too often focused on infrastructure and environmental sectors at the expense of the people being served. This is particularly evident in terms of investments in community first aid training that have been almost entirely lacking to date. As Kano et al. (2005) pointed out, “basic first-aid skills can be useful in treating minor injuries that commonly result from natural disasters in the United States. Yet there has been insufficient research on training and competence in first-aid skills among community residents” (p. 58).

Part of enhancing our nation’s disaster resilience, according to the U.S. Department of Homeland Security’s¹⁶ 2015 National Preparedness Goals, is education of individual community members. As the report states:

Individual and community preparedness is fundamental to our National success. Providing individuals and communities with information and resources will facilitate actions to adapt to and withstand an emergency or disaster…. Our national resilience can be improved, for example, by raising awareness of the techniques that can save lives through such basic actions as stopping life-threatening bleeding. (U.S. Department of Homeland Security, 2015, p. 6)

This first aid training and education enhances community preparedness and resilience, as well as social capital, by teaching techniques that save lives and reduce the burden of injuries or illnesses.

Community resilience is also strengthened by addressing the issue of public health surge capacity. It is commonly recognized that in a disaster, healthcare systems are overwhelmed, requiring a sudden surge in resources. To cope with surge in demand, the literature has generally focused on extending, expanding, or enhancing the efficiency of existing facilities and healthcare systems (Hick et. al., 2004¹⁷; Reeve et al., 2015¹⁸; Koh et al., 2006¹⁹). Rather than responding to the surge, DRAFA actually reduces the surge by training laypeople to treat minor injuries and keeping many survivors out of the healthcare system during and immediately after a disaster.

Unfortunately, while teaching disaster response community first aid meets key national goals, current first aid training is insufficient for effective disaster-caused medical emergencies. Nearly all current commonly-used first aid curricula, such as those of the American Red Cross (2017)²⁰ or National Safety Council (2019)²¹, are too broad and brief and they assume a normal, robust EMS (for instance by calling 911) and an intact comprehensive healthcare system—none of which is likely to be available during and immediately after a disaster. Smith et al. (2016) described a federally-developed pilot training program, Becoming an Active Bystander, that showed much promise. However, that curriculum evolved into a very simple and emergency-based (rather than disaster-based) 30-minute online program called You Are the Help Until Help Arrives (Federal Emergency Management Agency [FEMA], 2022²²). The program’s suggested first step, Call 911, is not all that helpful in a major disaster. Stop the Bleed (Stop the Bleed Coalition, 2022²³), a program developed by the American College of Surgeons, is actively being offered around the country and now the world. However, it is focused on just one aspect of disaster-caused medical emergencies, involves no scenarios, and can be done in as little as an hour. It is a well-respected program, but it is vastly insufficient in regards to the range of injuries and illnesses covered and due to the lack of available scenarios to practice. Even Community Emergency Response Team training (FEMA, 2019a²⁴), specifically designed for disaster response, only allocates two and a half hours to first aid training, far too little time to adequately address a key factor to those facing disasters and ultimately to community well-being and resilience.

Lack of Investigation Into Community First Aid Training

As has been noted, while the significant benefits of community first aid capabilities have been clearly identified (see especially Glantz & Ramirez, 2018²⁵) there is a lack of studies in the disaster literature examining how community-based disaster response first aid training should be conducted (Fatoni, et al., 2022). Challenges also persist in training spontaneous volunteers to coordinate with EMS or other official disaster responders. As noted by Paciarotti and Cesaroni, (2020), “spontaneous volunteers, if not supported or integrated into management planning, may be harmful to themselves and the others, because they may be the first on the disaster site, but not the most suited to carry out emergency operations” (p. 2).

Addressing this large and significant gap in the literature—between the documented importance of community members’ first aid response and the lack of research into developing the necessary first aid skills—is a key way to enhance community resilience and thus reduce negative impacts of disasters.

Barriers to Intervention: Self-Efficacy and Willingness to Help

Knowledge and skills are key first steps in effective response to disaster-caused medical emergencies, but there also needs to be confidence and willingness to intervene on the part of the public (Heard, et al., in press²⁶; Oliver et al., 2014²⁷; Van de Velde, et al., 2009). One way to evaluate confidence to respond is using Bandura’s (1977)²⁸ concept of self-efficacy, which he defined as one’s perceptions of how well they can execute courses of action required to deal with prospective situations. Higher levels of first aid self-efficacy in participants have been correlated with more positive outcomes (Benight & Bandura, 2004²⁹; Burns, 2014³⁰; D’Angelo, 2021³¹). However, at least one study questioned the relationship between self-efficacy and performance. Schumann et al. (2012)³² examined self-efficacy and wilderness first aid skills—from which DRAFA was developed—and reported no correlation between higher self-efficacy beliefs and performance of first aid skills.

Willingness to respond can also be a barrier to intervention (Kandakai & King, 2013³³; Oliver et al., 2014). Lack of knowledge, liability concerns, and personal safety may inhibit a community member from applying first aid, especially to non-family members or strangers. Other identified barriers in terms of community members responding to medical emergencies include bystanders’ presence and ambiguity (Fatoni et.al., 2022). However, disasters, with their generally more significant and very obvious medical needs, are different than the simple, one-victim studies in which these barriers were identified.

Islands and Disasters

Context is important (Kelman et al., 2011³⁴; Cortes et al., 2020³⁵). The hazards facing the CNMI are numerous and significant. To begin, many authors have pointed out the multi-faceted and significant hazards particular to small islands (Haynes et al., 2005³⁶; Kim et al., 2021³⁷; Kuleshov et al., 2014³⁸; Méheux et al., 2007³⁹; Pelling & Uitto, 2001⁴⁰). These hazards include earthquakes, typhoons and hurricanes, tsunamis, volcanoes, and rising sea levels. Many other factors also increase the vulnerability of islands to disasters, including geographic isolation, small physical size, small economies, limited natural resources, and poor infrastructure (Méheux et al, 2007). Additionally, the world often tends to ignore the disasters on small, out-of-the-way locales such as the Marianas (Arriola, 2020⁴¹; Wong & Cruz, 2018⁴²). With nearly fifty countries (Méheux et al., 2007), not to mention many territories, sharing this vulnerability, helping these regions become more resilient is an area of focus with significant potential for moving disaster science and safety forward.

The Northern Mariana Islands

In addition to the general vulnerability that goes with being a small isolated group of islands, the CNMI are specifically at risk for typhoons, tsunamis (Uslu et al, 2013⁴³), earthquakes, and rising sea levels. Typhoons (or cyclones) are the most significant hazard facing the Marianas and have been common throughout history. As Spennemann (2004)⁴⁴ pointed out, the Marianas are more prone to typhoons than the atoll groups to the south and the east, and Palau in the southwest. In 2018, Super Typhoon Yutu, the second strongest storm ever to hit the United States or its territories, unleashed torrential rains and winds of up to 180 miles per hour upon the CNMI (FEMA, 2019b⁴⁵). For all these reasons, the CNMI is a very appropriate place to study the efficacy of DRAFA.

Research Design

This study investigated the effectiveness of DRAFA in preparing community members to respond to disaster-caused medical emergencies prior to the arrival of organized and/or official help.

Research Questions

This study posed several questions regarding the efficacy of DRAFA. Our three research questions were:

1. Were knowledge and skills of disaster-focused first aid significantly improved by taking a DRAFA class?
2. Was self-efficacy of knowledge and skills of disaster-focused first aid significantly improved by taking a DRAFA class?
3. Was willingness to respond to disaster-caused medical emergencies significantly improved by taking a DRAFA class?

Intervention

Two classes of DRAFA were held, each running a total of twenty-four hours, spread out over three consecutive days. A full schedule of the class can be found in Appendix A. Class size ranged from 17 to 21 students. Participants in the first class were first responders (police and fire department) and Homeland Security personnel. Participants in the second class were first responders (police and fire department) and Homeland Security personnel, along with nursing students and community members.

The classes were delivered in the middle of the COVID-19 pandemic, impacting the delivery in several ways. Over 40 participants were recruited for both of the two classes, easily meeting enrollment targets. However due to COVID-19, less than half of those registered were able to participate. Also due to the pandemic, the instructor and all participants were masked throughout the classes, at times impacting communication and the development of class camaraderie. COVID-19 also made travel from the U.S. mainland more expensive, longer, and more tiring for the instructor.

Methods

We studied four constructs: skills, knowledge, self-efficacy, and willingness to help. The lead instructor evaluated participant first aid skills quantitatively using a skills check-list (see Appendix B). While not quantified, the lead instructor also tested participants’ first aid skills in scenarios—short (approximately half hour long), small-group (3-5 participants) simulations in which a participant would have a simulated disaster-caused medical emergency. If minimum competency was not demonstrated on initial testing, participants repeated skills and scenarios until competency was met.

Knowledge was assessed using pre- and post-tests. Pre-tests consisted of a 10-item multiple choice test (see Appendix C) which was provided at the very start of the class and then reassessed at the end of class using a 50-item standardized DRAFA multiple-choice test (see Appendix D). Likewise, self-efficacy and willingness to help (see Appendix E) were pre-tested at the start of class using the validated 15-item Remote First Aid Self-Efficacy Scale (Ritchie, 2021⁴⁶) and again at the conclusion of the class. Self-efficacy and willingness to act were scored on a 100-point scale, where means were expressed as percentages and differences between paired means as percentage points.

Data consisted of six values for each individual subject: pre- and post-measures for knowledge, self-efficacy, and willingness to act. These data were coded and manually entered into an Excel spreadsheet and stored on the first author's laptop until the conclusion of the research when the data were erased. Data met parametric normality requirements and so were analyzed by paired t-test comparing pre- and post-values for the three constructs matched by individual subject.

Study Site Description

This study was conducted on Saipan, the most populated island in the CNMI, with a population of approximately 47,000. The CNMI is a U.S. Territory located in the Western Pacific Ocean, 3700 miles west of Hawaii and 1600 miles east of the Philippines.

As previously mentioned, the CNMI are at particularly at risk for typhoons, with the second strongest such storm ever to hit the U.S. occurring in 2018 (FEMA, 2019b). In addition, the Marianas are at significant risk for tsunamis, earthquakes, volcanoes, flooding, and rising sea level (Biggs et al., 2015⁴⁷). Like many small, isolated island entities, the Marianas are particularly vulnerable to natural hazards due in part to their small size, geographical isolation, limited natural resources, small economy, and susceptibility to climate change (Méheux et al, 2005).

The people of the CNMI are diverse, including the indigenous Chamorro, the Refaluwasch or Carolinians, Fillipinos, and those of mixed Asian and Oceanic backgrounds. English is the language of commerce and education, but 83% of the population speaks a language other than English at home including Chamorro, Carolinian, Chinese, or Tagalog (Central Intelligence Agency, 2022⁴⁸).

Education levels compared to the rest of the US are relatively low, with 44% of adults lacking a high school diploma (Commonwealth of the Northern Mariana Islands Department of Commerce, 2017⁴⁹). Another 32% earned a high school diploma or GED as their highest educational qualification, about one-third the rate of the U.S. mainland.

The economy of the CNMI has been in decline in recent years with Gross Domestic Product numbers dropping significantly in the last two years for which numbers are available (U.S. Bureau of Economic Analysis, 2021⁵⁰) and population falling over 22% from 2000 to 2010 (U.S. Department of Health and Human Services, 2020⁵¹) and another 10% from 2010 to 2020 (U.S. Census Bureau, 2020⁵²). Median household income has decreased between 2015 and the present; as of 2020, 52% of the population was living in poverty (U.S. Department of Health and Human Services, 2020).

Examining the CNMI and disasters using the Social Determinants of Health framework (Adams et al., 2019⁵³), the islands have increased social vulnerability due to poverty, a shrinking economy, and educational levels. These issues are exacerbated by environmental factors such as geographic isolation and small size. Many of these factors are shared by other U.S. Territories and small island nations, thus the CNMI can serve as a model for other at-risk communities around the world.

Sampling and Participants

Staff of the Northern Marianas College, in conjunction with the CNMI Department of Fire and Emergency Medical Services and the CNMI Homeland Security and Emergency Management recruited participants. Efforts were made to recruit from all three of the populated islands—Saipan, Tinian and Rota. Initial recruitment was from the local fire departments, police departments, and Homeland Security. Participants were also recruited by social and print media.

Approximately three-quarters of participants identified as male. In terms of ethnicity, 84% identified as Pacific Islanders and 16% as Asians. Almost half of participants were firefighters, 13% were police officers, 13% were staff of Homeland Security, and 10% were nursing students, with 16% of the remaining participants being laypeople.

All participants were advised that their engagement was totally voluntary and that the classes were part of a research project.

Ethical Considerations, Researcher Positionality, Reciprocity, and Other Considerations

Institutional Review Board approval was granted by the University of Colorado School of Medicine on November 3, 2021 (COMIRB No: 21-4796).

The study was conducted with the full understanding that while the lead author had the proven ability to successfully teach DRAFA, effective participant learning was possible only with local community knowledge, understanding, and expertise. Five local community leaders, two from Northern Marianas College, one from Northern Marianas Emergency Management System, one from Northern Marianas Homeland Security, and a local educational consultant were fully involved in the design and execution of the study. All five were offered compensation for their time and expertise, with two of them declining, given the work was considered part of their full-time jobs.

Tuition and certification fees were waived for participants in the classes. In addition, snacks and lunches were provided each day to ensure the sessions started on time as the training site was held in the northern part of the island far from restaurants. Travel expenses, including airfare, housing, and meals were provided at no cost to participants traveling from islands other than Saipan.

Findings

This study investigated the effectiveness of DRAFA in terms of preparing first responders and laypeople to respond to disaster-caused medical emergencies. The study did so by:

• Pre- and post-testing of knowledge;
• Pre- and post-testing of self-efficacy regarding conducting first aid responses;
• Pre- and post-testing of willingness to respond to a disaster-caused medical emergency; and
• Testing participants regarding hands-on first aid skills and application of knowledge and skills in scenarios.

Two cohorts (n₁ = 21; n₂ = 17) completed pre- and post-tests for the constructs of knowledge, self-efficacy, and willingness to act. Distributions met normality requirements and parametric analyses were conducted using paired t-tests.

Strong and highly significant (p<.001) improvements in knowledge were found for both cohorts (t₁ = 16.13; t₂ = 13.75). The first cohort improved knowledge from a pre-test mean score of 43% to a post-test mean of 75% (+32% points), while the second improved means from 39% to 87% (+48% points).

Self-efficacy showed moderate and significant (p<.001) increases for both cohorts (t1 = 3.87; t2 = 4.64). The first cohort increased their self-efficacy from a pre-test mean of 70% to a post-test mean of 84% (+14% points), while the second cohort increased means from 57% to 87% (+30% points).

Willingness to act or respond was weakly and significantly (p<.05) found to increase for one cohort (t₁ = 2.25), but was not found for the other cohort (t₂ = 1.50; p=.16). The first cohort enhanced mean willingness to act from 94% to 98% (+4% points), while the second cohort was not found to have changed, with an average willingness of 94% at both pre- and post-test. This finding was likely due to the high number of subjects who responded with an anticipated 100% willingness in all situations to create both cohort averages well above 90%. This expected certainty meant little room for gain and consequently little or no change overall.

All participants demonstrated competencies in disaster first aid hands-on skills after repeated skills training. More importantly, these skills were demonstrated, along with knowledge acquisition, in applied scenarios.

Finally, participants, using a self-evaluation form, rated the class and their learning very highly. Participants were asked to evaluate their learning of disaster response first aid and to evaluate the overall quality of the class on scales of one through ten. Participants rated their learning as a 9.7/10 and their overall evaluation of the class as a 9.8/10.

Conclusions

Disasters are becoming more common and more destructive. At the same time, societal resources are being stretched thin, meaning communities need to be increasingly robust and more self-reliant. Engaging community members in emergency medical response has often been identified as a way to increase this resilience. However, research regarding the effectiveness of training community members to respond has largely been ignored. This small pilot study was designed to investigate whether a disaster-focused first aid training could significantly improve participant knowledge, self-efficacy, and willingness to intervene. The study demonstrated that a DRAFA class does in fact increase participants’ ability and self-efficacy to respond to disaster-caused medical emergencies.

Implications for Practice

DRAFA was shown to be an effective way to train non-medical first responders and community laypeople in first aid techniques to respond to disaster-caused medical emergencies. Based on these findings, DRAFA should be both more widely offered and further studied to improve its efficacy.

The public health literature features no shortage of articles discussing the role of resilience in mitigating the impacts of disasters. However, most of this is focused on theory as opposed to application. DRAFA offers public health professionals an applied tool that can be tested and improved, providing communities with a concrete method to strengthen resilience.

DRAFA can also develop community resilience by reducing the need for surge capacity following a disaster. A disaster-caused surge of injured residents can easily overwhelm public health capacity. Community members trained in DRAFA can treat minor injuries and thus keep many survivors out of the healthcare system during and immediately after a disaster.

In viewing DRAFA through the lens of the “Essential Public Health Services,” the course and its development touch on at least half the activities identified by the Centers for Disease Control (2021)⁵⁴. As demonstrated by the findings, the course effectively educates participants about first aid. The development of the course in the CNMI—bringing together police, fire, Homeland Security, EMS, and higher education—strengthened networks and partnerships. The efforts created, championed, and implemented a plan to educate participants in two classes, with plans to deliver additional classes at a later date. The DRAFA classes helped build and develop a cadre of skilled laypeople to respond to the next disaster. Finally, this study improved emergency medical response through education and evaluation.

The CNMI sociodemographic characteristics provide a representative example of a small and isolated island with a limited and shrinking economy. Along with geographic and economic issues, CNMI has relatively low educational levels and relatively high poverty levels. Thus, in terms of the sociodemographic characteristics of the Northern Marianas Islands, and resulting social vulnerabilities (Adams et al., 2019), they provide a model for similar U.S. Territories and small island nations. As DRAFA was shown to be effective in the CNMI, it is reasonable to assume that it should be effective in these other challenged locations.

Strengths and Weaknesses of the DRAFA Classes

In terms of improving efficacy, the lead and local authors conducted an after-action review (Harvard School of Public Health, 2013⁵⁵) shortly following the second DRAFA class to consider what went well, what could be enhanced, and implications for the future. Identified successful aspects included the emphasis on hands-on skills and realistic scenarios. The Subjective, Objective, Assessment and Plan (SOAP) notes—booklets that included immediate, core assessment steps, response rubrics, and scenario documentation pages—were found to be helpful, as were imbedded videos portraying the severity of various types of disasters. A number of suggested improvements were identified as well. These included breaking up lectures more with hands-on skills to maintain participant interest and increasing participant engagement with activities such as table talks, aiming for improved balance of passive and active learning. Other suggestions were to simplify PowerPoint slides (less content per slide and more illustrations) and better integrate and/or insert videos into PowerPoints. In terms of future DRAFA delivery, with local instructors, it was recommended that PowerPoint slides be sent out early for adequate preparation. There was strong agreement that scenarios be written up with detailed description of the medical emergency, clear “patient” signs and/or symptoms identified, and well-defined learning outcomes for facilitators to evaluate. Finally, it was recommended that a scenario “cheat sheet” be developed for facilitators, a write-up that would lay out best practices for running and especially for de-briefing.

Limitations and Strengths

This study had a number of limitations, including sample size, geographic/cultural uniqueness, participant diversity, lack of validation of some evaluation tools, fall-out from COVID, and issues of retention. The sample size was less than 40, limiting statistical interpretations. The CNMI is a unique location for the classes with their own distinctive disaster risks and culture; it may be difficult to extrapolate findings to other locations. The participants in the classes were mostly first responders. While they demonstrated significant learning, the first responders were not representative of laypeople who typically lack emergency knowledge and experience. They were also less representative in terms of gender, as about three-quarters of the participants were male.

The written final, measuring knowledge, as well as the skills check-lists have not been externally validated. COVID-19 made recruiting participants more difficult, resulting in lower participation and a less representative sample. Questions have been raised regarding retention of skills and knowledge over time, with studies finding overall poor retention (Berden et al., 1994⁵⁶, Schumann, et al., 2012).

Strengths of this study include location, local involvement, enthusiasm, and commitment, leading to networking and enhanced social capital, and the real-world delivery of training. The study site is representative of many small islands which share similar vulnerabilities around the world (Méheux et al., 2005). Thus, the findings can be extrapolated to a number of at-risk locations.

The study was strongly encouraged and embraced from start to finish by a variety of local leaders and residents, particularly from Northern Marianas College. The resulting collaborations increased networking and social capital, and thus further enhanced community resilience. The involvement has led to professional development opportunities for CNMI academicians and disaster and EMS leaders.

In addition to the research, this project trained dozens of local residents in DRAFA, including several participants who intend to become instructors. This support demonstrates the need and the relevance of the training, and the potential for further research and offerings.

Recommendations and Future Research Directions

Efforts to further study and improve DRAFA should be strongly supported. DRAFA offerings should continue and be expanded. Communities will be more resilient if DRAFA is integrated into existing programming such as Community Emergency Response Teams (see for example the Mississippi Youth Preparedness Initiative⁵⁷), and higher education academic credit offerings. Support should be solicited from federal, state, and regional governments as well as international funders to expand and subsidize DRAFA offerings. Translating DRAFA into other languages could expand its impact globally.

In terms of specific research directions, the content of DRAFA should be reviewed by a panel of experts to provide consensus on what should and should not be covered. DRAFA should be studied with a truly representative group of community laypeople (as opposed to a group comprised of mainly first responders). DRAFA should be studied in more locations, with different disaster risk factors and different cultures. Finally, research regarding the effectiveness of evaluation tools, particularly the written exam and skills and scenarios checklists should be conducted.

DRAFA has been shown to be effective in preparing community members to respond to disaster-caused medical emergencies prior to the arrival of organized help. Future research can help make DRAFA an even more effective tool to increase the resilience of communities in U.S. territories, throughout the country, and across the world.

Acknowledgements. The authors would like to acknowledge a number of CNMI community leaders for their assistance in this study, starting with Patrick George (Department of Fire and Emergency Medical Services, CNMI) and Patrick Cepeda (Homeland Security, CNMI) who were instrumental in providing a real-world perspective on disasters and disaster response in the CNMI. Other CNM leaders who made the study possible include: Patricia Coleman, Interim Dean, Northern Marianas College Cooperative Research, Extension, and Education Services; Gerald J. Deleon Guerrero, Special Assistant, CNMI Homeland Security and Emergency Management; Dennis C. Mendiola, Commissioner, Saipan Department of Fire and Emergency Medical Services (DFEMS); Raymond T. Dela Cruz Jr., Commissioner, Tinian DFEMS; Steven K. Mesngon, Deputy Commissioner, Rota DFEMS; and Joel O. Hocog, Assistant Fire Chief, Rota DFEMS. The authors would also like to acknowledge and thank Dr. C. Ryan Akers, of Mississippi State University and the National Project Director, MyPI.

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