In sub-Saharan Africa, 41% of all deaths and 39% of the morbidity burden can potentially be addressed by emergency care ^[1],^[2]. Road traffic injuries may dramatically increase this burden in the coming years ^[3]. In many emergencies, prompt and adequate care can increase the likelihood of survival and recovery. Pre-hospital care is a vital initial step; however, it is often unavailable in sub-Saharan Africa. When an emergency occurs, basic first responders often constitute the sole source of initial help, and emergency transport often consists of a ride in taxis, private cars, or public transport ^[4],^[5]. Studies in Ghana and Uganda demonstrated that training basic first responders leads to improved provision of help in the absence or anticipation of medical care ^[6]–^[8]. Therefore, the World Bank has promoted first aid training as an inexpensive way to save lives in sub-Saharan Africa.

The distinct African burden of disease and injury, the limited access to formal health care, the strong embeddedness of cultural remedies, and poverty all call for specific first aid guidelines. However, first aid training in sub-Saharan Africa is often based on handbooks prepared outside of the continent that are not adapted to the African context. Although well-intentioned, such resources sometimes lead to misdirected, inadequate, or even harmful training instructions. Several African Red Cross National Societies expressed the need for first aid materials adapted to the African context. We are not aware of any evidence-based reference that comprehensively addresses how basic first responders should be trained to manage emergency situations in an African context. Since evidence-based reviews with relevance to low- and middle-income countries are scarce, this added to the importance of our work ^[9]. Our guidelines are intended to guide those responsible for first aid programmes and to form the basis of African training materials. We defined first aid as “appropriate and beneficial help to a suddenly ill or injured person which is initiated as soon as possible and continued until that person has recovered or medical care is available”. These guidelines focussed on first aid interventions requiring minimal or no equipment.

The guidelines represent the consensus judgment of an expert panel taking into account findings from systematic reviews on the following topics: stroke, heart attack, fever, fits, diarrhoea, rash, wounds and injuries, poisoning, and emergency childbirth. This topic selection was based on published injury and disease statistics for sub-Saharan Africa ^[1],^[2]. For the topics of choking, unconsciousness, and heart arrest, we used the evidence-based guidelines with instructions for basic first responders published by the International Liaison Committee on Resuscitation (ILCOR) ^[10].

Overall, we screened 24,000 references and selected 143 publications to provide the evidence base for the guidelines. The systematic reviews allowed us to learn about practices that try to make the best use of the limited resources available. Examples of such practices that were considered by the panel include ash for hand washing ^[15],^[16], homemade oral rehydration solutions for diarrhoea ^[17], early breastfeeding for emergency childbirth ^[18],^[19], fever measurement by touch ^[20], tepid sponging for fever ^[21], boiled and cooled water for wound cleansing ^[22], application of honey or aloe vera, and dressings from banana leaf or potato peel for burns ^[23]–^[27].

The complete guidelines (Text S2) include a narrative synthesis of the results of the systematic reviews and recommendations for each included topic. We have chosen to report here the evidence and recommendations for snakebites as a sample of the guidelines.

Writing guidelines is only the beginning and should be followed by measures to support implementation in practice. Therefore, these new guidelines formed the basis of a flexible training materials kit that comes on a DVD. This DVD will be available to those responsible for first aid training programmes in Africa. The training materials include an electronic version of the manual illustrated with hundreds of quality illustrations including youths, adults, and elderly people from multiple ethnic and religious backgrounds. The manual is available in English, French, and Portuguese and describes for every condition the most important signs to look for and actions to take. Currently, didactical posters and videos are being developed to demonstrate the different procedures. Providers of first aid courses can pick what they need from the DVD to compose their first aid courses for their specific target audience.

Although the guidelines attempted to be generic for sub-Saharan Africa, there are local specificities that need to be addressed in order to apply the training materials. For example, misunderstandings and mistrust regarding health information may arise when the biomedical approach is at odds with local perceptions and management. Advice that incorporates local terms, perceptions, and preferences is considered to be more convincing ^[36]. Therefore, an implementation guide is also available to assist those responsible for first aid programmes on ways to adapt the training materials.

Between June and December 2010 we piloted the training materials and implementation guide in Uganda and Swaziland. These pilots include focus group discussions on whether the illustrations are understood to evaluate clarity, and field-testing the feasibility of more complex instructions. For this purpose, individuals with different levels of experience in first aid (from novice to trainer) were asked to perform specific first aid tasks under different test conditions. The test conditions included performing the task when being provided with drawings only, with drawings and written instructions only, or after the demonstration by a trainer. An observer recorded if the participants completed the task correctly or incorrectly.

Implementation of AFAM in the Red Cross national societies from Namibia, Mozambique, South Africa, Malawi, Uganda, Swaziland, the Comoros, and Kenya is planned. We are also developing a strategy to formulate a similar set of guidelines and training materials for South Asia. Furthermore, because first aid training is often used as an entry point for primary prevention, we have commenced a project to formulate evidence-based preventive measures that can be used in addition to the first aid guidelines described in AFAM.

The authors have declared that no competing interests exist. For reasons of transparancy we declare that Stijn Van de Velde received funding from the Laerdal Foundation of Acute Medicine for a trial on bystander helping behaviour for myocardial infarction following first aid training.

This guideline was funded by the Belgian Red Cross–Flanders, the Flanders International Cooperation Agency (FICA), and by the Belgian Directorate-General for Development Cooperation (DGD). SVDV, EDB, and PV are in employment at the Belgian Red Cross-Flanders and were involved in the design of the guideline development plan, data collection and analysis, decision to publish, and preparation of the manuscript. FICA and DGD were not involved in the content or development of the guideline.

Provenance: Not commissioned; externally peer reviewed.

Members of the AFAM expert panel were Jimmy Volmink (chair) (South African Cochrane Centre, Medical Research Council; Faculty of Health Sciences, Stellenbosch University), Benson Agbro (Nigerian Red Cross), Omar Ahmed (International Centre for AIDS Care & Treatment Programs, Ethiopia), Jenny Bakker (South African Red Cross), Paul Bitex Okot (Uganda Red Cross), Stephen Gichuhi (University of Nairobi, Kenya), Walter Jaoko (University of Nairobi, Kenya), Sylvia Khamati Anekha (Kenya Red Cross), Hayley Macgregor (University of Sussex, United Kingdom), Navin Naidoo (Cape Peninsula University of Technology, South Africa), Jérôme Sebaganwa (Rwandan Red Cross), and Philippe Vandekerckhove (Belgian Red Cross-Flanders).

Evidence reviewers were Emmy De Buck (Belgian Red Cross-Flanders) and Stijn Van de Velde (Belgian Red Cross-Flanders).

Peer reviewers were Emmanuel Bottieau (Institute of Tropical Medicine Antwerp, Belgium), Anja De Weggheleire (Institute of Tropical Medicine Antwerp, Belgium), Els Duysburgh (International Centre for Reproductive Health, Belgium), An Sermon (University Hospitals Leuven, Belgium), Marleen Temmerman (International Centre for Reproductive Health, Belgium), and Lee Wallis (Stellenbosch University, University of Cape Town, South Africa).

The coordinator of the pilot test was An Vanderheyden (Belgian Red Cross-Flanders).

T. Young (South African Cochrane Centre; RYTD Consultancy) wrote the expert panel meeting minutes and provided support in editing the manuscript.