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A prospective, longitudinal, comparative analysis of the World Health Organization / International Committee of the Red Cross Basic Emergency Care Course on emergency medicine knowledge and confidence among recent medical school graduates

International Journal of Emergency Medicine volume 18, Article number: 8 (2025) Cite this article

Abstract

Background

The Basic Emergency Care (BEC) course was created by the World Health Organization (WHO) in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM) to train frontline providers in low-resource settings. This study aims to evaluate long-term retention and maintenance of emergency care knowledge and confidence among University of Nairobi School of Medicine graduates after completing the BEC course.

Methods

This longitudinal, prospective, comparative study was conducted with recent graduates of the University of Nairobi School of Medicine from October 2021 to May 2023. Participants’ retention of emergency medicine knowledge was assessed comparing a pre/post course test and a multiple-choice examination 12 to 18 months after completing the BEC course. A survey assessed participants’ confidence in managing patients with emergencies 12–18 months after completing the BEC course using a 4-point Likert scale. These results were compared to a control group of recent University of Nairobi School of Medicine graduates who did not take the BEC course.

Results

The follow-up test scores were lower than the immediate post-course test scores, which suggests some knowledge loss over time. Compared to the control group, the BEC participants had higher test scores during the follow-up period although the difference was not significant. There was no difference between most of the immediate post-course and follow-up survey responses. On follow-up evaluation, BEC participants reported a significant decrease in confidence in understanding emergency drugs and managing an obstructed airway and a patient requiring immobilization. However, compared to the control group, BEC participants had significantly higher self-reported confidence in most areas assessed by the survey.

Conclusion

The WHO BEC course is effective for emergency care training for medical students at the University of Nairobi. However, the participants’ decrease in knowledge and confidence 12 to 18 months after the BEC course suggests the need for regular refresher courses.

Background

Emergency medicine (EM) training is a relatively new, but necessary aspect of medical education worldwide [1]. As formalized EM education expands across Europe and the United States, it is still in the early stages of development in many low- and middle-income countries (LMICs) [1,2,3]. EM training is critical as emergency conditions are the leading cause of death and disability worldwide, with a disproportionately high affliction in LMICs [4].

In 2019, the seventy-second World Health Assembly (WHA) acknowledged the importance of emergency care systems development, while emphasizing that frontline health workers often care for patients with emergency conditions without dedicated emergency care training [5]. The seventy-second WHA urged member states to “provide dedicated training in the management of emergency conditions for all relevant types of health providers, including… integrating dedicated emergency care training into undergraduate nursing and medical curricula” [5].

There is a wide range of emergency medicine training in medical schools across the globe. Multiple types of EM courses and clinical rotations have been proposed and implemented with varying success [6,7,8]. Courses often utilize a multi-modal teaching format, including clinical experience, simulation, procedural skills, and lectures [6,7,8,9].

One pivotal, open-access course that has been established is the WHO/ICRC Basic Emergency Care Course (BEC) [10]. The World Health Organization (WHO) in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM) created the BEC course to train frontline providers in low-resource settings. The seventy-sixth WHA called for all frontline health workers to receive WHO BEC training [11]. This five-day course focuses on the management of acutely ill and injured patients [10]. The effectiveness of the BEC course at increasing emergency care knowledge and confidence has been well documented, and successful courses have been conducted for medical officers, clinical officers, and nurses in many countries [12,13,14,15].

In 2021, we studied the BEC course as a training tool for graduating medical students at the University of Nairobi [16]. Given the perception that medical students in Kenya receive little to no additional formal emergency medical training in medical school [17] the Kenya Ministry of Health, in its Kenya Emergency Care Strategy 2020–2025 report, recommended incorporating “emergency medical care training in preservice curricula of all medical training institutions and universities.” Upon completion of medical school, these physicians will work in hospitals throughout the country with a broad range of resources. Often, physicians who completed their intern year at a Kenyan hospital felt that they had received inadequate training on resuscitation and emergency medicine skills [17].

Our prior study was the first of its kind to demonstrate the effectiveness of the BEC course for improving emergency care knowledge and confidence in this unique population. The study showed a significant increase in participants’ confidence and knowledge of managing acutely ill and injured patients immediately following the course [16]. Other BEC studies in Uganda, Tanzania, Zambia, and Nigeria similarly only evaluated participants immediately post- course [12, 14, 15]. A study in Sierra Leone surveyed participants six months after the course [13], but to our knowledge, no studies have evaluated retention of knowledge and confidence beyond six months.

This study aims to support the WHA 72 and 76.2 goals of strengthening the “evidence base for emergency…interventions” [5, 11] by evaluating the long-term retention and maintenance of emergency care knowledge and confidence among University of Nairobi School of Medicine graduates after completing the BEC course.

Methods

This longitudinal, prospective study was conducted with recent graduates from the University of Nairobi School of Medicine from October 2021 to May 2023. Participants of the initial BEC course in October 2021 were recruited via an advertisement in the University of Nairobi School of Medicine Class of 2021 WhatsApp (Whatsapp LLC, Menlo Park, California) group. Participants were selected on a continuous, first-come basis, and all students in the 2021 graduating class were eligible to participate. The course was limited to 30 participants according to guidelines from the African Federation for Emergency Medicine (AFEM) [18].

Thirty recent medical graduates participated in a 5-day BEC course in October 2021. The BEC participants’ knowledge was assessed with a 25 question, multiple-choice question (MCQ) examination 12 to 18 months after the course and compared with prior published pre-course and immediate post-course results in the same cohort [16]. A post-course survey assessed participants’ confidence in managing acutely ill and injured patients using a 4-point Likert scale with responses ranging from 1 (strongly disagree) to 4 (strongly agree) and 1 (not confident at all) to 4 (very confident). The same post-course confidence survey was also administered immediately after the course and 12 to 18 months after the course. The post-course MCQ exam and survey were the standard versions developed as part of the BEC training package that are available via email from AFEM (scientific@afem.info) [19]. All 30 participants completed the examination and confidence survey immediately after the BEC course in October 2021, while 25 of them completed the follow-up examination and survey between September 2022 to May 2023 (Fig. 1).

Fig. 1
figure 1

Study participant selection

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A control group was recruited from graduates of the University of Nairobi School of Medicine Class of 2021 who did not participate in the BEC course offered in October 2021. Participants in the control group were recruited via an email sent to all members of the University of Nairobi School of Medicine Class of 2021 who had not participated in the BEC course. They were recruited from September 2022 to May 2023. Inclusion in the study was based on voluntary responses, and 34 participants were recruited for the control group (Fig. 1). All control group participants completed the same post-course examination and confidence survey that was administered to the BEC course participants.

De-identified participant data was prospectively collected during the course and managed on a password-protected computer. Quantitative data from the BEC participants' immediate post-course and follow-up examinations and surveys were compared using the paired t-test. Quantitative data from the BEC participants' and control group participants’ examinations and surveys were compared using two-sample t-tests. All analysis was completed using R statistics software [20].

Results

Demographics

A total of 30 students from the graduating class at the University of Nairobi School of Medicine participated in the BEC course in 2021. Of the 30 participants who took the BEC course, 25 physicians completed a follow-up test and survey between 12 to 18 months after finishing the course. Sixty percent of the follow-up participants were female, while 40% were male. The control group was made up of 34 physicians from the same graduating medical school class as the intervention group, but they had no prior BEC training. Sixty-one percent were male, while 39% were female.

The immediate post-course test and survey were completed by all 30 BEC participants, while the follow-up test and survey were completed by 25 BEC participants. All 34 physicians in the control group completed the test and survey. The 5 BEC participants who were lost to follow-up were excluded from the immediate post-course and follow-up pairing and the control group comparison.

Test results

The results of the pre-course, immediate post-course, follow-up, and control group tests scores are shown in Table 1. The pre-course and immediate post-course data has been published prior [16]. The follow-up test scores (87.5, 95% CI: 82.7, 92.4) were significantly lower than the results of the immediate post-course tests (95.4, 95% CI: 94.4, 96.3) (Table 2). The follow-up test scores (87.5, 95% CI: 82.7, 92.4) were higher than the pre-course test scores (82.6, 95% CI: 79.2, 85.9), but the results were not statistically significant (Table 3). Similarly, the follow-up test scores (87.5, 95% CI: 82.7, 92.4) were higher than the control group test scores (82.6, 95% CI: 79.5, 85.7), but the results were not statistically significant (Table 4).

Table 1 Comparison of pre-course test with immediate post-course test, follow-up test and control group
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Table 2 Comparison of Immediate post-course test with follow-up test
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Table 3 Comparison of pre-course test with follow-up test
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Table 4 Comparison of follow-up test and control group
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Survey results

The results of the immediate post-course, follow-up, and control group survey results are shown in Tables 5 and 6. While there was no significant change between most of the immediate post-course and follow-up survey responses, there was a significant decrease in confidence in understanding emergency drugs, managing an obstructed airway, and immobilizing a patient. Participants also report a significant decrease in confidence in other providers’ knowledge and skills to handle emergency care patients and their own level of preparedness to care for all emergency patients on the follow-up survey (Table 5).

Table 5 Comparison of per question scores between immediate post-course and follow-up surveys
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Table 6 Comparison of per question scores between the one-year follow-up and control group surveys
Full size table

Compared to the control group, the follow-up evaluation of the BEC participants showed significantly higher self-reported confidence across most of the survey questions. However, there was no significant difference in confidence between the two groups in “feeling prepared to see emergency care patients in my clinical setting” and “understanding the ABCDE’s of basic emergency care” (Table 6).

Discussion

This study evaluated the long-term retention of knowledge and confidence in emergency care following the BEC course. Overall, the follow-up test scores were lower than the immediate post-course test scores, which suggests knowledge loss over time. In our previous study, there was an increase in immediate post-course test scores compared to pre-course test scores, indicating an improvement in knowledge [16].

Follow-up test scores were higher than pre-course test scores, although not statistically significant, indicating there is likely some improvement in emergency medicine comprehension even several months after taking the course. Medical knowledge attrition is a well-documented phenomenon, underscoring the need for regular refresher courses [21, 22].

Compared to the control group, the BEC participants had higher test scores during the follow-up period, although the difference was not statistically significant. We believe future studies aimed at assessing the long-term effectiveness of the BEC course with a larger sample size may demonstrate statistical significance.

When comparing individual survey questions between the one year follow up and the control group, the BEC cohort had significantly higher confidence scores. BEC course participants were overwhelmingly more comfortable in handling emergency cases when compared with the control group. For example, in response to the question, “I feel comfortable handling any patient requiring emergency care”, compared to their peers who did not take the BEC, they were significantly more comfortable (Table 6). Overwhelmingly, clinical confidence was higher among the BEC cohort. These findings are of particular interest, since both of these groups are now practicing physicians.

However, similar to the attrition of knowledge test scores, we saw a loss of confidence in the BEC cohort 12–18 months after the course. Although most BEC studies have only evaluated knowledge and confidence changes immediately post-course, a study in Sierra Leone examined knowledge retention among BEC participants six months after the course [13]. Similar to our study, immediate post-course test scores were significantly higher than the pre-course test scores but demonstrated a decrease in knowledge six months after the BEC. Their findings suggest that there is knowledge loss as soon as six months after completion of the course.

The statistically significant loss of confidence in emergency care knowledge underscores the importance of re-training of emergency courses as well as the importance of supportive mentorship post-course for effective knowledge, skill retention and clinical confidence. High acuity, low occurrence (HALO) clinical events and procedures, such as those practiced in the BEC, are well defined in the pre-hospital literature [23]. Physicians encounter these HALO scenarios involving acute airways, resuscitations, obstetric emergencies and rare life-saving procedures. Regular re-trainings, involving simulation-based education and deliberate practice, have been demonstrated to maintain HALO event readiness and knowledge retention [24,25,26].

In Kenya, graduating medical students receive varying degrees of training in emergency care [27]. Physicians taking care of acute or unstable patients, which include junior house officers, need training in emergency care given their high level of autonomy in those roles. Kenya hospitals have varying course requirements for medical officers, such as Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and/or Advanced Trauma Life Support (ATLS), but not all medical students have the opportunity to take these training courses. These courses have a narrower scope, typically require retraining and re-certification every 2–3 years, and can be expensive [28].

The BEC course takes a broad approach to acute emergencies, providing a foundation for stabilizing acutely ill or injured patients. Providing the BEC to new medical school graduates makes it possible to instill these foundational concepts before their internship. The BEC course is not a substitute for a multi-year emergency medicine specialty training program; however, the BEC course can increase new medical school graduates’ familiarity with emergency care, prepare them for HALO events and can be more widely implemented than specialized emergency medicine training due to the short-course structure. It may also increase interest in emergency medicine as a medical specialty by exposing new physicians to emergency care.

The need for re-training could potentially be addressed by the recently launched BEC Hybrid course available online through the WHO Academy [29]. This online course allows health care providers to complete a self-paced online BEC course followed by a 2-day in-person Practical Skills training. The BEC Hybrid course may be a time-conscious and cost-effective option for providers aiming to refresh their BEC knowledge and skills without repeating a 5-day in-person BEC course.

While the target attendees of the BEC course are health care providers in resource-limited settings, this study focused on medical school graduates from a major academic medical center in Nairobi, Kenya. The participants in this study likely had higher baseline knowledge and clinical skills compared to BEC attendees in other settings. By contrast, courses taught in Uganda and Tanzania recruited and trained mixed attendees, including physicians, nurses, nursing officers, allied health professionals, midwives, pharmacists, or technicians [15]. The pre- and post-course test results in these studies were markedly lower than those seen in our study. We suspect this is due to baseline knowledge differences among the groups based on the effect of prior training and job experience.

Our results underscore the need for ongoing education and training in acute and emergency care. Ongoing team based acute care training and availability of supportive mentorship has been shown to improve knowledge and skill retention amongst participants [30]. Further studies can be done with implementation of re-training, deliberate practice and post course mentorship to assess the level of retention of knowledge and skills.

Limitations

This BEC training was offered exclusively to physicians who were new graduates of the University of Nairobi. This limits the comparison to other BEC studies with differing composition of trainees. As such, results of pre-course and post-course scores, knowledge retention, and confidence are not likely comparable to other cohorts due to selection bias among the trainees. Our study compared a first-come, first-served cohort of enrollees against a voluntary control group of first-year intern-level physicians who did not take the course. Since they were not randomized in selection, both the course and control participants may reflect groups of physicians with a special interest in emergency medicine. As such, we may have a false negative conclusion of no difference in overall knowledge during the follow-up period as compared to a general medical graduate. Five physicians in the experimental group were lost to follow-up. While this is not a large percentage, it may also cause incorrect conclusions regarding course material retention, in either a positive or negative direction.

The BEC course is generally taught in English, and all Kenyan medical students speak English, in addition to Kiswahili. The same cannot be said for participants from other African countries, where the native or national language may not be English. This may limit comparability across studies as communication differences or limitations may be responsible for score increases or decreases as opposed to actual differences in learning and retention.

Conclusions

The WHO BEC course is effective for emergency care training for medical students at the University of Nairobi. There was increased confidence among newly practicing physicians who took the BEC compared to controls. However, in our study, participants had a decrease in knowledge and confidence 12 to 18 months after the BEC course, which suggests the need for regular refresher courses. Participants of the BEC course should consider and plan for regular refresher training to account for emergency care knowledge and confidence loss over time.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

AFEM:

African Federation for Emergency Medicine

BEC:

Basic Emergency Care: Approach to the acutely ill and injured Course

EM:

Emergency Medicine

HICs:

High-income countries

ICRC:

International Committee of the Red Cross

IFEM:

International Federation for Emergency Medicine

LMICs:

Low- and middle-income countries

ToT:

Training of Trainers

WHO:

World Health Organization

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Acknowledgements

We would like to thank the University of Nairobi for providing facilities to support this training. A special thanks to Dr. Trufosa Mochache and Dr. Pascal Mugemangango for providing valuable support and guidance to the Nairobi BEC Team. We also thank Julianne Cyr, MPH, CPH, for her contribution to the literature review for the discussion of this manuscript.

Funding

This research study was supported by funds from the Department of Emergency Medicine, Brown University, the UNC Global Health Scholarship Program and personal professional development funds from UNC faculty. The funding from these sources was used to purchase supplies and equipment for the BEC training and support the researchers’ and course facilitators’ travel expenses. These funding sources did not play a role in the design of the study, the collection, analysis, and interpretation of data, or the writing of the manuscript.

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Authors and Affiliations

  1. Department of Emergency Medicine, University of Vermont Medical Center, Burlington, VT, USA

    Nichole Michaeli

  2. Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA

    Andrew Beck, Giovanna De Luca & Grace W. Wanjiku

  3. Kenyatta National Hospital, Nairobi, Kenya

    Mary Gitau

  4. MaineHealth/Coastal Maine Global Health Fellowship, Rockport, ME, USA

    Derek Lubetkin

  5. Avenue Hospital, Kisumu, Kenya

    Derick Ochieng

  6. Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Justin G. Myers

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Contributions

NM obtained IRB approval, obtained grant funding, coordinated and taught the BEC course, collected data, and wrote the methods section of the manuscript. AB coordinated and taught the BEC course, and wrote the discussion and limitations section of the manuscript. GD coordinated and taught the BEC course, collected data and wrote the discussion and conclusions section of the manuscript. MG coordinated and taught the BEC and provided critical input into the manuscript. DL coordinated and taught the BEC Course and collected data. DO coordinated and taught the BEC Course and provided critical input into the manuscript. GW coordinated and taught the BEC course and provided critical input into the design and execution of the study. JM taught the BEC Course, collected data and provided critical revisions to manuscript. All authors read and approved the final Manuscript.

Corresponding author

Correspondence to Justin G. Myers.

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Ethics approval and consent to participate

The authors certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This study was reviewed and approved by the Kenyatta National Hospital—University of Nairobi Ethics and Research Committee, protocol P703/12/2020 and the Lifespan IRB, protocol 1736842–5. All participants provided written consent to participate in the study.

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Not applicable.

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The authors declare no competing interests.

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Michaeli, N., Beck, A., De Luca, G. et al. A prospective, longitudinal, comparative analysis of the World Health Organization / International Committee of the Red Cross Basic Emergency Care Course on emergency medicine knowledge and confidence among recent medical school graduates. Int J Emerg Med 18, 8 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12245-024-00797-w

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  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12245-024-00797-w

Keywords

International Journal of Emergency Medicine

ISSN: 1865-1380

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