Cabin crew aero medicine and first aid training in China

Abstract Aero medicine and first aid training is essential in preparing qualified cabin crew for in-flight medical emergencies. Nonetheless, it has always been regarded as a challenging aspect of cabin crew training. Cabin crew have been facing a more complex situation when conducting their duties onboard due to COVID-19. This study aims to explore the current status of aero medicine and first aid training in China. Using the snowballing technique, 17 participants were recruited for the in-depth semi-structured interview, including cabin crew from 9 airlines in China, first aid instructors from airline training centers, and lecturers from universities. Based on thematic analysis, four themes were extracted: required competencies, factors affecting first aid behaviors, course content and instructional strategies. Findings indicated that most airlines in China emphasized training their cabin crew in aero medicine and first aid. However, some conducted recurrent training once every two years, which was insufficient for skills and knowledge retention. Automated External Defibrillators (AED) were rarely equipped onboard. MedAire was not available for all airlines in China. The results pointed out the shortfalls on aero medicine and first aid aspect in China and can help improve the in-flight first aid facilities and optimize the training programs.


Introduction
The primary responsibilities of cabin crew on commercial aircraft are passenger safety and comfort (Zorlu & Nebol, 2022).As "front-line service experts," they are the only airline personnel with almost continual consumer contact during the flight (Babbar & Koufteros, 2008;Karatepe & Eslamlou, 2017).Cabin crew are trained to obey regulatory rules as well as industry-wide and airline-specific customer service and emergency protocols by their employer, the airlines.In the case of a medical emergency while in flight, they must respond quickly, conduct a preliminary inspection, and give pre-hospital treatment.According to article 121.419 of Rules for the Accreditation of Large Aircraft Public Air Transport Carriers(Ministry of Transport of the People's Republic of China (2005), the cabin crew should be able to deal with abnormal conditions such as illness and injury of passengers or themselves, including being familiar with emergency medical equipment.The national vocational skill standard for civil aviation cabin crew of China (2019) describes in detail the cabin crew's duties related to aero medicine and first aid regarding their job positions.During the COVID-19 and post-pandemic period, cabin crew are also responsible for preventing in-flight transmission of the disease by implementing appropriate infection control measures required by airline companies.The in-flight Infection Prevention and Control(IPC) training was organized and conducted by airline companies for cabin crew as well (Bjørnstad, 2020;Ryu et al., 2021).
There has been a steady increase in the number of emergencies occurring during flights.This is due to the increasing number of aviation travellers, including senior citizens, and the prevalence of chronic illnesses among passengers (Hinkelbein et al., 2013;Intas et al., 2021;Low & Chan, 2002).According to the annual report of the International Civil Aviation Organisation (ICAO) (Presentation of 2018Air Transport Statistical Results, 2018), global air passenger traffic reached 4.3 billion passengers, a 7.1% increase over the previous year.Long-distance flights may have a more significant negative impact on the elderly and those with preexisting medical conditions (Fariduddin et al., 2019;Mahony et al., 2008).It is challenging to provide first aid onboard the aircraft.First, as the cabin pressure is maintained at 7,000-8,000 feet, passengers receive less oxygen than the ground.This may cause many emergency medical problems.Besides, it may affect the recovery of many diseases.Second, in a passenger medical incident, there can be delays of more than 20 minutes to several hours before expert assistance is available (Beltrame et al., 2001).Moreover, the presence of professional medical personnel cannot be entirely relied upon.Third, managing medical emergencies and resuscitation in a cramped cabin surrounded by anxious passengers with limited medical resources can be extremely stressful for the cabin crew (Yu & Liang, 2021).As the overall number of air passengers grows, China has seen more and more inflight medical emergencies.China Eastern Airlines experienced 179 cases from 2016 to 2017, averaging one every two days (Peple's Daily Online, 2017).
The cabin crew play a crucial role in performing first aid onboard.Previous research reported that more than half of the medical cases were handled by cabin crew (Dowdall, 2013;Kim et al., 2017).Therefore, cabin crew must be trained to an appropriate level of proficiency in aero medicine and first aid.ICAO requires cabin crew to complete the training before they are assigned as a cabin crew member, and annual recurrent needs to be completed as well.The European Union Aviation Safety Agency (EASA) stipulates the training content of cabin crew aero medicine and first aid training through legislation, such as the physiology of flight, emergency treatment in aviation, application of cardiopulmonary resuscitation (CPR), basic survival first aid training, travel health and the use of aircraft equipment.Due to the increasing number of in-flight medical emergencies and diversions in China, the carrier, along with doctors and experts, spent a year analyzing those emergency cases to publish China's first in-flight first aid handbook, which can guide cabin crew and passengers in dealing with in-flight emergencies (Yang, 2018).
Nevertheless, it is difficult for cabin crew as laypersons to master all the professional knowledge and skills during a short period of intensive training (Chi et al., 2021;Fariduddin et al., 2019;Mahony et al., 2008).Non-technical skills, such as effective communication, collaboration, and leadership, are crucial for enhancing patient safety (Sevdalis et al., 2012).However, according to Rasmussen et al. (2012), professional training conducted by a medical and health sciences education faculty was more focused on technical knowledge and skills rather than explicitly geared to non-technical skills.After initial training, first aid skills deteriorate rapidly (Anderson et al., 2012), as time passes by due to lack of practice and the chances are low to encounter various medical problems onboard.Previous studies have documented low mastery of technical skills and knowledge retention in first aid among cabin crew (Fariduddin et al., 2020;Mahony et al., 2008).These may result in declines in emergency treatment quality and efficiency delivered to the patients by the cabin crew.Scholars in China asserted it is important for cabin crew students to master solid first aid knowledge for the specific in-flight environment to ensure the safety of passengers, and qualifications and genuine first aid capabilities of cabin crew need to be further upgraded (Chi et al., 2021).Yao et al. (2009) pointed out there is a need to strengthen training on illnesses caused by the flight environment as well as life-threatening medical conditions.This study aims to explore the current status of aero medicine and first aid training for cabin crew in different airlines in China on various aspects in order to offer suggestions on making better training programs that can improve cabin crew's first aid performance onboard.Meanwhile, the findings obtained can be used for developing the blended-learning module based on the learners' needs, experts' points of view, and industry requirements.

Cabin crew, the first-aider in the sky
First aid is defined as the first and immediate assistance given to anyone suffering from a minor or severe illness or injury (First aid manual: 9th edition, 2009), with the goal of saving lives, preventing deterioration, and promoting recovery.The University of Castilla-La Mancha(UCLM) describes that first aid includes comprehensive treatment of minor conditions, such as applying a bandage to a cut, and initial treatment of serious conditions prior to the arrival of professional medical assistance, such as performing cardiopulmonary resuscitation (CPR) while waiting for an ambulance.First aid is typically administered by a person with only fairly basic medical training.
The cabin crew, also referred to as a flight attendant, steward/stewardess, or air host/air hostess, is a member of the aircrew on commercial flights, many business jets, and certain government aircraft.The primary duty of the cabin crew is to ensure the safety of the aircraft and passengers (Cabincrew, 2023;Emirates Group, 2023).According to IATA's annual review 2022, the number of in-flight emergency patients was anticipated to increase due to the recent increase in the number of air travellers, including the elderly and passengers with underlying diseases, and the number of in-flight emergency patients was expected to rise.Chandra and Conry (2013) noted that in addition to the cramped and tiny cabins with limited space for medical care, the low likelihood of receiving assistance from a medical doctor, nurse, or medical assistant has an indirect effect on passengers and causes a variety of complications.
Previous studies investigated the most common emergency health problems onboard and the vital medical conditions leading to flight diversion (Kim et al., 2017;Kodama et al., 2018;Martin-Gill et al., 2018;Paxinos et al., 2021).It is shown that the most common in-flight medical problems were syncope, heart problems, gastrointestinal problems, respiratory symptoms, anxiety, and burns.According to Valani et al. (2010), cardiac, neurological, gastrointestinal, and syncope incidents account for the majority of flight diversions.Intas et al. (2021) concurred that passengers with heart or respiratory difficulties were at risk.Kim et al. (2017) compared in-flight first aid performed by cabin crew and medical volunteers.They reported first aid performed by the cabin crew alone in 52% of the cases and by medical volunteers in 47.8% of the cases.The most commonly reported causes for first aid performed by the cabin crew and medical volunteers were burns and syncope.According to British Airways data, one medical event occurred for every 11,000 passengers on average, with 70 per cent handled by cabin crew (Dowdall, 2013).A series of recent studies have indicated that most airlines provide medical equipment onboard in order to respond to potential medical emergencies (Intas et al., 2021;Yu & Liang, 2021).Recent studies have shown that First Aid Kits (FAK), Universal Precaution Kits, Emergency Medical Kits(EMK), supplemental oxygen and AEDs are available onboard for many airlines around the world (Intas et al., 2021).During COVID-19, The Supplementary Infection Prevention Kit (SIPK) has been added onboard for Infection Prevention (IP) purposes in Chinese airlines, according to Xu et al. (2023).Previous researchers also reported that the majority of airlines, and especially those that travel long distances and across oceans, had a remote ground medical centre to provide medical assistance in case there was no doctor on the flight and had 24 hours of medical help at their disposal (Intas et al., 2021;Sigurdsson, 2017).On the other side, Chandra and Conry (2013) concluded that volunteer physicians should have knowledge about the most common in-flight medical incidents and medical equipment available onboard, coordinate their therapy with the flight crew and remote resources, and provide care within their scope of practice when medical emergencies occurred during the flight.In addition, Yu and Liang (2021) investigated the relationship between first aid affect, work-related hardiness, and self-efficacy of first aid provided by cabin crew in an effort to improve cabin crew's first aid performance onboard.They discovered significant positive relationships between these factors and concluded that airlines must strengthen cabin crew's work commitment to improving first aid self-efficacy.Furthermore, the first aid affect was regarded as an important training goal.Table 1 shows the previous studies on in-flight medical aspects and cabin crew's role regarding first aid onboard.

Cabin crew first aid training
As first-responders onboard, cabin crews are responsible for ensuring the health of passengers (Bjørnstad, 2020;Yu & Liang, 2021).They are trained to recognize common medical problems, provide first aid to passengers in need as well as assist medical personnel on board.The cabin crew take charge of making the initial assessment of the ill passenger and informing the captain of the situation.They may request assistance from the onboard medical staff as needed.Additionally, the captain may decide to consult with ground-based medical assistance (GBMS) so that the experts in aviation and emergency medicine can provide support from the ground up (Sigurdsson, 2017).According to Dowdall (2013), training the flight personnel in first aid ensured that passengers received prompt and accurate care.Every cabin crew on duty must go through extensive training to become a certified first aider.The ICAO Standard that addresses cabin crew training states, "An [aircraft] operator shall establish and maintain a training programme, approved by the State of the Operator, to be completed by all persons before being assigned as a cabin crew member.Cabin crew shall complete a recurrent training programme annually."According to IATA (IOSA Standards Manual ISM Edition 15 Remote Audit Revision 1, 2022), cabin crew must receive first aid recurrent training annually, including life-threatening medical emergencies, cardiopulmonary resuscitation, management of injuries and illnesses, and handling first-aid and medical equipment and supplies.Therefore, aero medicine and first aid are mandatory content included in initial and recurrent training for cabin crew.Mahony et al. (2008) noted that there are no internationally agreed-upon standards for training cabin crew, resulting in various companies training crew members more adequately.Furthermore, there was a considerable variation in terms of duration and content on aero medicine and first aid for cabin crew.Some companies required their cabin crew to be tested using automated external defibrillators and cardiopulmonary resuscitation every two years.In contrast, others requested cabin crew to refresh and demonstrate their knowledge annually and cover all subjects required by the General Civil Aviation Authority (GCAA) and resuscitation guidelines for CPR (Intas et al., 2021;Yu & Liang, 2021).Those variations can lead to differences in the ability of cabin crew to handle medical problems onboard.
Generally, the literature on cabin crew aviation first aid training is limited.Some researchers investigated competencies in order to develop or optimize training programs for the cabin crew (Kim & Park, 2014;Opatha & Rathnayake, 2018;Paethrangsi, 2020;Sotomayor-Castillo et al., 2021), while others specifically focused on exploring ways to improve training outcomes of cardiopulmonary resuscitation (CPR) (Fariduddin et al., 2019;Mahony et al., 2008).Studies have shown that in the modern medical field, non-technical skills, such as communication, teamwork, and leadership, play a significant role in improving patient safety, knowledge, and technical skills.These skills should be thoroughly mastered because they are crucial for daily work (Sevdalis et al., 2012).Winkelmann et al. (2016) suggested a simulator-based air medical training program called Christoph Life, which is an innovative educational concept focusing on CRM elements and team training.Participants were trained and accessed in different scenarios with a fully equipped and movable helicopter simulator.More recent attention has been drawn to Infection prevention (IP) performance among aircraft cabin crew and commercial airline protocol for preventing in-flight transmission during the COVID-19 pandemic, along with various control measures for passengers and cabin crew (Nick et al., 2020;Pongpirul et al., 2020;Ryu et al., 2021;Xu et al., 2023).Overall, these studies highlighted the need for necessary preventive measures.It was concluded that

Review
Secondary data Most conditions are treated by the crew with a simple painkiller, while there are more complex conditions that require a different treatment, such as oxygen administration to patients with respiratory problems.In some cases, medical advice and assistance is sought from passengers who are healthcare professionals.Some companies require crews to be trained and certified every two years for the use of AED and CPR.All aircraft have an emergency medical kit with a limited number of drugs and universal precaution kits in cases where there is a risk of communicable disease.Due to the spread of COVID-19, the WHO has issued specific guidelines for both protecting crews from the virus and treating suspicious passenger.Dowdall (2013).Is there a doctor on the aircraft?Top 10 in-flight medical emergencies.
In-flight medical emergencies N/A Data provided by airlines About three quarters of in-flight medical emergencies are managed by cabin crew.The range of equipment and drugs onboard varies but can be extensive.Doctors who volunteer to help the crew manage an incident should remember to "do no harm" and practise within the limits of their training and knowledge.
(Continued)  In-flight medical emergencies, the first aid providers onboard, airline protocols Literature review Secondary data The majority of in-flight medical events are benign and will resolve spontaneously.Death on board is a rare occurrence.Most events are managed by cabin crew without the assistance of an onboard health professional.In the event of an in-flight medical emergency, a doctor is ethically obliged to help when requested.The emergency medical kit (EMK) available on board contains medical equipment and drugs that may be used for clinical examination and treatment of the passenger.The kit is to be used when a trained medical doctor is available for assistance on the aircraft.Most aircraft carry AED for use in the case of cardiac arrest.
a high level of IP awareness and training experience could improve IP performance among cabin crew members.As a result, appropriate medical training and IP awareness strategies were critical for preventing in-flight infection transmission.The medical problems which happen most for either passengers or cabin crew and the usage of medical equipment should be attached importance during cabin crew aero medicine and first aid training (Intas et al., 2021;Kim et al., 2017;Liang & He, 2020).
The theories that came up by previous researchers related to first aid training and education are Theories of Reasoned Action (TRA) and Planned Behavior (TPB).TRA developed by Martin Fishbein and Icek Ajzen in 1967, aims to explain the relationship between attitudes and behaviors within human action.An individual's decision to engage in a particular behavior is based on the outcomes the individual expects will come as a result of performing the behavior.TRA suggests that stronger intentions lead to increased effort to carry out the behavior, which in turn increases the likelihood that the behavior will be carried out.TPB was developed out of TRA and improved TRA, By adding to TRA the component "perceived behavioral control", Ajzen (1985) extended TRA to better predict actual behavior.Perceived behavioral control involves the perception of the individual's own ability to perform the behavior (Ajzen, 1991).The theory suggests that people are much more likely to intend to enact certain behaviors when they feel that they can enact them successfully.In this study, the research explores the cabin crew's attitude toward learning and rendering first aid, self-efficacy to perform first aid onboard, the content that cabin crew and the instructors perceive necessary, and the effective strategies for better outcomings.Fishbein and Yzer (2003)created the Integrative Model of Behaviour Prediction (IMBP) based on these two theories.They incorporated those theories to design interventions that aim to improve learners' learning outcomes for short and long-term behaviour change.Education would be most effective if the learner's intention is known.Learners' self- Online interview 13 76.5 confidence in their ability to help can be increased by understanding their motivation to help and incorporating messages that build on their understanding of their role and how they can make a difference (Ajzen, 2011;Ajzen & Madden, 1986;Fishbein & Yzer, 2003;Miller & Pellegrino, 2018).
According to the IMBP model, any given behaviour is most likely to occur when a person has a strong intention to perform the behaviour, possesses the necessary skills and abilities to perform the behaviour, and there are no environmental constraints preventing the behaviour from occurring (Fishbein & Pequegnat, 2000).This theory contends that in order to establish realistic goals, it is advantageous for the educator to investigate the requirements and preferences of the learners before developing the learning approach.When investigating the current status of cabin crew aero medicine and first aid training in this study, the factors that affect first aid behaviors and cabin crew's needs related to this theory need to be fully taken into account in order to make improvements to the training course.Besides, the Kirkpatrick model is a widely used training evaluation model.Tamkin and his colleagues describe it as "The best-known and most widely used framework for classifying evaluation.(Tamkin et al., 2002)" Kirkpatrick's model includes four evaluation levels, including reactions, learning, behaviour, and results (Kurt, 2016).Many researchers adopted the Kirkpatrick model to evaluate the training outcomes of first aid training programs (Outcome Measurement Toolkit, 2021) as well as in the aviation field and regarded it as a valuable tool (Abdelhakim et al., 2018).
Overall, previous studies focused on either reviewing medical problems that happened onboard or some specific part of cabin crew aero medicine and first aid training.Literature and previous research indicate that effective cabin crew aero medicine and first-aid training require more attention.The number of in-flight medical emergencies and diversions in China has been increasing nowadays (Yang, 2018).The qualifications and genuine first aid capabilities of cabin crew need to be further upgraded, and it is necessary to strengthen training on illnesses caused by the flight environment as well as life-threatening medical conditions (Chi et al., 2021;Liang & He, 2020;Yao et al., 2009).Aero medicine and first aid training for cabin crew in China have not been thoroughly presented in any previous research.In addition, learners' requirements and experts' opinions regarding aeromedicine and first aid must be identified.Consequently, this study aims to fill these research gaps.

Materials and methods
This study follows the steps suggested by Elo et al. (2014) to carry out the content analysis and employs a hybrid approach to code and analyze the interview data (Swain, 2018) to enhance its trustworthiness and quality.

Data collection
In order to probe and gain insights and information about the cabin crew aero medicine and first aid training in China, semi-structured in-depth interviews were employed to collect participants' data between October 2022 and January 2023.Considering the convenience of the interviewees and the COVID-19 situation, the researcher adopted face-to-face and online interview modes to conduct the semi-structured interviews.Each interview took about 1 hour, considered a reasonable length suggested by Adams.An interview guide was developed based on the research aim and previous cabin crew training literature.The researcher sought advice from two qualitative experts who are familiar with the topic to ensure the validity of the interview questions.One question was revised, and another was added to the interview guide per their suggestions.The semi-structured interview guide was divided into participants' demographic profiles, onboard first aid duties and tasks, and cabin crew aero medicine and first aid training (Appendix A).Interview piloting was conducted before the implementation of formal interviews.All the interviews were recorded by a digital recorder and transcribed for further data analysis.

Sampling and recruitment of participants
Purposive sampling, along with the snowballing technique, was employed.According to Elo et al. (2014), purposive sampling is appropriate for qualitative studies in which the researcher is interested in interviewing informants with the most extensive knowledge of the topic.Furthermore, it is essential to state the principles and criteria for recruiting participants to establish credibility (Neuendorf, 2011) and to ensure transferability (Hsieh & Shannon, 2005).The researcher recruited (3) years of working experience should be: less than five years, 6-10 years, 11-15 years, 16-20 years, above 20 years;(4)affirmation should cover three layers of airlines in China: four major airlines, medium size airlines, small size regional airlines.(5) First aid instructors and lecturers should have solid backgrounds in both teaching and flying.There is no commonly accepted sample size for qualitative studies because the optimal sample depends on the purpose of the study, the research questions, and the richness of the data.Data saturation may indicate the optimal sample size (Guthrie et al., 2004;Sandelowski, 1995).Fariduddin et al. (2019) interviewed 16 participants about basic life support training, while Tsaur et al. (2020) also recruited 16 participants to explore cabin crew hassles.In total, 17 participants were invited for semi-structured interviews, including 12 cabin crew from 9 airlines in China, two first aid instructors from airline training centres, and three lecturers from universities teaching aero medicine and first aid courses with aviation backgrounds.Table 2 displays the participants' profile.

Ethical considerations
This study adopted semi-structured interviews to collect participants' data.Participants were recruited to attend the interviews by using the researcher's personal relationships.Before conducting formal interviews, all participants were informed of the study's purpose, content, and data collection procedures and that the data collected would be used for the sole purpose of the study.
They were assured that their information was kept confidential and their participation was entirely voluntary so that they were willing to participate in the interview.Furthermore, participants involved in this study were adults and had provided their consent to participating this study.To ensure information confidentiality, the researcher is fully aware that this study has the responsibility to protect the data obtained during the research.The findings reported must be in a real and complete way, and did not falsify or tamper with the results.The study was conducted in accordance with the Helsinki Declaration.

Data analysis
Thematic analysis which was developed by Virginia Braun and Victoria Clarke (2006), is a method that has become a widely-used tool or tehnique for qualitative research, both in psychology and beyond (Terry et al., 2017 p.17).According to Percy et al. (2015), thematic analysis can be used to analyze data collected through a qualitative survey-a kind of qualitative survey using interviews (often) that are semi-structured-to investigate subjective experiences of objective things.It helps researchers understand various aspects of a phenomenon that participants talk about frequently or in depth, and the ways in which those aspects of a phenomenon may be connected.The reason for using thematic analysis in this study is to probe into the data and get an accurate picture of the cabin crew first aid training regarding the current situation and what it should be.Nvivo 11 was used to code and organize the data.Thematic analysis can be used in an inductive, a deductive way or a combination of both.This study adopted a hybrid approach incorporating a top-down, deductive, theoretical, and bottom-up, inductive, data-driven process.The former produced a set of a priori codes that came from the research aims, research questions, and individual questions asked in the interviews, whereas the latter approach resulted in a series of posterior codes derived from an examination of data generated (Swain, 2018).Two coders worked together to code and analyze the data.One was a cabin supervisor with aero medicine and first aid training background, mainly responsible for analysis, while the other coder, who was familiar with thematic analysis, followed up on the whole analysis process and categorization.In this study, the data analysis included three phases.First, the researcher created a set of priori codes summarised from research questions and previous literature, such as emergency response capability, anti-stress ability, reassure passengers, First Aid Kit(FAK), Universal Precaution Kit(hygiene kit), CPR, burn, trauma, simulation and so on.Second, the main coder began to search for meanings and patterns in the conversations, and both coders coded and checked meaningful units.Then, those units were combined and classified into categories.For example, "for the CPR part, a manikin called Annie was used for instruction.Our trainer will teach and show us the steps first.Then, we practise on Annie who plays the role of a passenger who is suffering from cardiac arrest.Later we are required to pass the practical assessment." and "We do mock-up and get assessed in simulator during recurrent training.There are scenarios mixed with different medical emergencies, decompression, cabin fire and so on."These were classified into the same category of simulation-based learning.New codes were added to the priori codes as well.For example, "mental health first aid" and "effective communication with MedAire" were added to the theme of course content.In this study, 132 pages of transcription data were generated.313 units were coded, 12 units were removed, and 301 valid units remained.When the two researchers had different opinions on the classification, they proceeded to unit analysis, presented the original data, and engaged in a discussion to reach a consensus.Third, the a priori and a posteriori codes were sorted into 25 categories and refined.The two coders confirmed those categories and agreed with 25 categories to be further classified into four themes: core competencies required, factors that affect first aid behaviors, course content and instructional strategies of cabin crew first training.Figure 1 illustrates the content analysis of the cabin crew aero medicine and first aid training process using Nvivo11 software.
The trustworthiness of thematic analysis is frequently described using terms like credibility, dependability, conformability, transferability, and authenticity.The following efforts were made to improve the trustworthiness according to Elo et al. (2014): first, to improve credibility, the researcher adopted semi-structured interviews for data collection and explained each question to ensure the participants would fully understand.Moreover, all the interviews were recorded, transcribed and double-checked with participants after the interviews about their intentions.Second, peer review and member-checking method was utilized to enhance the dependability.Two peers from university who hold PhD degrees to ensure the reliability of the research method and instrument.Then, interview piloting was conducted.Two researchers worked together to analyze data and verify the results' correctness.Third, the detailed research process was presented for transferability, including sampling and recruitment, data collection and analysis.In addition, data source triangulation was used to increase the reliability and ensure the quality of this study.Triangulation refers to using multiple methods or data sources in qualitative research to comprehensively understand phenomena (Patton, 1999).The researcher collected the data through semistructured interviews as well as from related documents, such as cabin crew manuals, training materials, standards and rules issued by organizations and countries.

Results
Four themes regarding aero medicine and first aid training for cabin crew were generalized in this study: competencies required, factors that affect first aid behaviors, course content and instructional strategies.Most categories under the main themes align with the previous literature (Mahony et al., 2008;Fariduddin et al., 2019;Fariduddin et al., 2020;Bjørnstad, 2020;Ryu et al., 2021;Yu & Liang, 2021;Kim & Park, 2014;Opatha & Rathnayake, 2018).Nevertheless, new findings such as psychological diathesis and commitment to work and society under theme one, fatigue and environmental constraints under theme two, effective communication with Med-air and mental health first aid under theme three, and problem-based learning and blended learning under theme four go beyond the aero medicine and first aid training perceived by other researchers.Figure 2displays the structure of cabin crew aero medicine and first aid training found in this study.

The competencies required related to the aspect of first aid onboard
The core competencies of cabin crew related to aero medicine and first aid consist of psychological diathesis, the capability to handle medical emergencies, collaboration and teamwork, accurate communication, situational awareness, and commitment to work and society.Table 3 lists a few supportive quotes within this theme.
All participants(n = 17) perceived psychological diathesis as a critical competency related to onboard first aid.It was also regarded as the prerequisite to provide timely and accurate first aid onboard the aircraft.The capability to handle medical emergencies was emphasized by most participants(n = 13) and considered the main goal for aero medicine and first aid courses consistent with previous studies and related documents (Chi et al., 2021;Fariduddin et He, 2020;Ministry, 2005).Most participants agreed that efficient teamwork between the flight crew and good collaboration with different parties(e.g.medical personnel, patients and their companions) would significantly improve the chances of saving lives.Accurate communication was also pointed out by participants(n = 5).They suggested using accurate words to avoid misunderstanding or passing wrong information to relevant parties.Instructors and lecturers mentioned the importance of developing the cabin crew's situational awareness.They claimed that cabin crew need to always know about what's going on around them and stay vigilant about passengers' condition.Some cabin crew members mentioned commitment to work and society, especially when conducting infection prevention and control duties onboard during COVID-19 and postpandemic period.

The key factors that affect cabin crew's first aid behaviors
The key factors perceived by participants that affect cabin crew's first aid behaviors onboard include professional knowledge and skills, environmental constraints, fatigue, self-efficacy, fatigue, perceived norm and attitude towards first aid.Table 4 lists a few supportive quotes within this theme.
The majority of participants agreed that the mastery of first aid knowledge and skills would affect the cabin crew's first aid behavior onboard (n = 16).If cabin crew possess sound knowledge and skills, they are more likely to act and feel confident in dealing with medical emergencies.Environmental constraints were mentioned by participants, including turbulence when rendering first aid to passengers, turbulence during critical stages of flight(e.g.Take-off and landing), busy and complicated service procedures, as well as passengers crowding and watching the process of cabin crew rendering first aid.Those environmental constraints would hinder or affect the cabin crew's first aid behaviour.Two participants pointed out the cabin crew's fatigue.They claimed that if the cabin crew were too tired, they would hardly even notice the sick passengers so the response would be delayed.Self-efficacy refers to an individual's belief in his/her capability to perform tasks, which is domain-specific (Bandura, 1977).Some crew members(n = 10) reported that low selfefficacy would make them feel hesitant and even lost when medical cases happen onboard, especially when encountering serious medical emergencies.Perceived norm refers to the social pressure one feels to perform or not perform a particular behavior.When it comes to cabin crew regarding their first aid behavior onboard, most of the participants(n = 13) claimed that since their occupation was cabin crew, they were expected to perform first aid to passengers or crew members in need.What's more, they were committed to their job and willing to offer medical assistance by applying what they were trained in.With regards to the "attitude" towards, some cabin seniors and instructors(n = 3) indicated that a few junior cabin crew tended to wait for others to act instead of taking the initiative by themselves at the beginning of a medical emergency, especially wait for their seniors to respond first.All participants claimed that they hold a positive attitude towards learning first aid because they may use the knowledge and skills to save lives one day onboard during their duty.

The content of the cabin crew aero medicine and first aid course
The course content suggested by participants covers medical emergency equipment, basic knowledge of in-flight first aid, CPR onboard, trauma care, serious medical emergencies, minor medical problems, mental health first aid, and effective communication with Med-air.Table 5 lists a few supportive quotes within this theme.
Regarding the "course content", all participants(n = 17) believed medical emergency equipment onboard is mandatory learning content.All cabin crew must master what kind of medical equipment are onboard the aircraft, what medicine and tools are inside of them, where they are located, who can open and use them, how to use the items that cabin crew are allowed to administer and standard opening and closing procedures of each equipment.FAK, Emergency Medical Kit(EMK), hygiene kit and portable oxygen bottles were reported by participants.AED was mentioned by one participant from Sichuan Airlines, which is only available on Airbus 350 type of aircraft in his company.Hence, the researcher checked with the other eight airlines' participants, and they confirmed that there were no AEDs onboard the aircraft of their companies.However, a few participants(n = 2) claimed they were trained to use AED, even though no AED was onboard.For serious medical emergencies, heart disease, trauma, choking, childbirth, epilepsy, syncope, infectious disease, food positioning and death on the aircraft were mentioned by the majority of participants.All participants(n = 17) believed cardiopulmonary resuscitation(CPR) was a vital skill for cabin crew to save lives onboard, which must be trained regularly and adequately.The techniques of treating trauma were considered another critical focus for cabin crew aero medicine and first aid training(n = 15).However, some participants reported that they were not confident in treating wounds, fractures and soft tissue injuries because they did not receive enough training and lack of practicing the related techniques(n = 7).The first aid instructors suggested infectious disease should be included in the aviation first aid course curriculum in colleges and universities for cabin crew college students as the foundation because there was not enough time to teach trainees knowledge in detail during cabin crew initial training.Unlike serious medical emergencies, minor medical problems often happen on board, such as burns, air sickness, asthma, hyperventilation, abdominal conditions, hypoglycemia, altitude sickness, panic attacks, etc.Therefore, it is also necessary for the cabin crew to learn and master how to handle those medical incidents (n = 8).The first aid instructors(n = 2) and some cabin crew(n = 2) also mentioned that the basic knowledge of first aid and physiological aspects of flying should be included in the training course, for it is required by CAAC(Civil Aviation Administration of China), and most participants are lack of this knowledge.Instructors, lecturers, and some senior cabin crew reported that more attention should be paid to mental health problems these days for both crew members and passengers because it is related to flight safety, not only for crew and passengers' heath.They believe it is necessary for cabin crew to know someone is experiencing a mental health problem, whether a passenger or colleague.MedAire is a medical assistance company that provides remote assistance to several commercial airlines in the United States (Chandra & Conry, 2013).Most airlines, especially airlines that travel long hours and cross the ocean, where it is difficult to land immediately, have a land assistance centre like MedAire to provide medical assistance (Intas et al., 2021).Some lecturers and cabin crew members(n = 3) with international airline backgrounds agreed on the importance of land medical assistance centres which can provide practical guidance for crews to handle medical emergencies when no doctor is onboard.They pointed out that cabin crew need to know the procedure to connect with MedAire and provide appropriate information about the patient so that they can provide correct medication and first aid following instructions from MedAire.Nevertheless, all participants working in the nine airlines in China reported no medical assistance centre could provide medical assistance for onboard emergencies (n = 15).

Strategies to enhance learning outcomes
Apart from the traditional instructional strategies, such as lecture, demonstration-performance, practice and assessment, five categories are identified for this theme, including classic case study, simulation-based learning, problem-based learning, blended learning, and regular repetition.Table 6 lists a few supportive quotes within this theme.
Regarding the theme "Instructional strategies", most participants believe the case study, which happened onboard or experienced by cabin crew, is an ideal way to attract learners and make the content more impressive.On top of that, it was mentioned that case studies should be combined with other instructional methods.All participants regard simulation-based learning as a practical way to help cabin crew master and apply theoretical knowledge in practice.Although a few participants claimed that simulation could not replace actual disposal, ensuring every cabin crew can experience various medical cases happening onboard is impossible.The simulation can be used as an alternative for actual disposal.Instructors also suggested cabin crew students in college can get first aid education as early as possible and apply what they learned for real-world practice to accumulate practical experience and become increasingly proficient in this area.Compared with traditional lecturing, many participants(n = 9) believe problem-based learning is a more active way to facilitate participation and teamwork.Especially for recurrent training, when time is limited, working in teams to handle different medical problems that can happen onboard is a critical training outcome.However, a few participants (3) thought lecturing was still an important way to deliver the face-to-face course, even though it needed to be more interesting.The blended-learning approach is supported by all participants(n = 17) for its convenience and efficiency.Meanwhile, the lecturers and instructors(n = 5) pointed out that the ratio of the face-to-face section should be more than the e-learning section to ensure sufficient practice for learners as well as the foundational theoretic knowledge to be taught.As participants reported, large airlines, such as Air China and China Eastern Airlines, used e-learning and face-to-face instruction for aero medicine and first aid training.However, face-to-face instruction remained the major method for most medium-and smallsize airlines.Most participants(n = 12) mentioned the importance of repeating practical skills and refreshing knowledge for retention.They stated that most cabin crew generally needed more practice opportunities, so the key points of techniques were quickly forgotten or mistaken, which could cause faulty operation.Through repetition, knowledge and skills can be refreshed and reinforced.

Discussion
According to Pineda (2010), training is a key approach to human resource development and achieving organizational objectives.Past studies on cabin crew training focused on food safety (Abdelhakim et al., 2018(Abdelhakim et al., , 2019;;Speakman & Grout, 2019), Crew Resource Management(CRM) (Bennett, 2019;Kolander, 2019;Paethrangsi, 2020), Safety Emergency Procedure(SEP) (Flykt, 2020;Rhoden et al., 2008), in-flight infection prevention and training approach (Fang et al., 2022;Kim & Park, 2014;Ryu et al., 2021;Xu et al., 2023).Furthermore, in previous literature, much attention was paid to CPR as part of the cabin crew first aid training (Anderson et al., 2012;Fariduddin et al., 2019;Mahony et al., 2008).Many researchers investigated in-flight medical problems and reported the most commonly happened ones (Chandra & Conry, 2013;Kim et al., 2017;Kodama et al., 2018;Paxinos et al., 2021;Valani et al., 2010).However, in the academic field of aviation, there has yet to be research on aero medicine and first aid training for cabin crew in China, and the comprehensive status has not been presented in any previous research.
The results show that the cabin crew hired by airlines in China must be trained in aero medicine and first aid during initial and recurrent training and be qualified for flying, which is aligned with previous literature for airlines in other countries (Bjørnstad, 2020;Fariduddin et al., 2019Fariduddin et al., , 2020;;Intas et al., 2021;Yu & Liang, 2021).Four main themes with 24 categories were extracted from interview data on cabin crew aero medicine and first aid training.These included required competencies, factors affecting first aid behaviors, course content, and instructional strategies.

Theoretic implications
Competency-based education (CBE), also referred to as "competency-based training," has been adopted by industries, professions, and national training systems all over the world nowadays (Irvine & Kevan, 2017).According to Suzanne and her colleagues, the aviation industry has also adopted CBE to train skilled personnel for over a decade (Kearns et al., 2017).The training programs were developed based on the CBE approach to train pilots, maintenance engineers, air traffic controllers, cabin crew, and so on (Gangabissoon et al., 2020;Kearns et al., 2017;Kim & Park, 2014;Larrea et al., 2022).In this study, the core competencies related to in-flight first aid can be classified into six categories.There are psychological diathesis, the capability to handle medical emergencies, collaboration and teamwork, accurate communication, situational awareness and commitment to work and society.Apart from knowledge and technique requirement, which refers to the capability to handle medical emergencies, the findings of the other five categories indicated that non-technical skills play an essential role in cabin crew aero medicine and first aid training.Some of the findings concur with previous studies.Fariduddin et al. (2019) include effective communication, teamwork among the crew members, decision-making, and situational awareness in the non-technical skills for developing effective CPR skills.Other scholars list communication, teamwork and leadership (Rasmussen et al., 2012;Sevdalis et al., 2012).Moreover, in this study, those non-technique skills related to in-flight first aid have been probed deeply and specified by the researcher.On top of that, "psychological diathesis"and "commitment to work and society" are new findings compared with previous literature.Psychological diathesis is regarded as the most fundamental competency for cabin crew to render proper first aid onboard and also the critical educational goal for aero medicine and first aid training by participants because cabin crew need to remain calm and brave so that they can apply what they learned to actual disposal.
The theories relating to emergency response behaviour suggest that first aid education must consider many components to be relevant for short-and long-term behaviour change, such as demographic characteristics, culture, attitude, and exposure to other variables (e.g.media).According to IMBP, first aid behavior is most likely to occur if a person has a strong intention to perform the behavior, if a person possesses the necessary skills and abilities to perform the behavior, and if there are no environmental constraints that prevent the behavior from being performed (Fishbein & Pequegnat, 2000;Fishbein & Yzer, 2003).In this study, six factors that affect cabin crew's first aid behaviors onboard were extracted from the data: professional knowledge and skills, environmental constraints, cabin crew's fatigue, selfefficacy, perceived norm and attitude towards first aid.The findings confirm the components from IMBP, while a new category, "cabin crew's fatigue," emerges.This result ties well with previous studies wherein cabin crew fatigue.According to ICAO, fatigue is defined as a physiological state of reduced mental or physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload that can impair a crew member's alertness and ability to operate an aircraft or perform safetyrelated duties safely.Reports for the European Aviation Safety Agency(EASA) found that cabin crew reported the most contributing factors to fatigue were "long days," "early starts," "flying during hours when I would normally sleep," and "short recovery time between duties" (Dijk et al., 2019).Fatigue has an impact on cabin crews' overall health and may affect their performance on safety-related tasks.With flight operations impacting cabin crew's experiences in fatigue, sleep and mental health, various countermeasures were suggested to be implemented to better support cabin crew (Feiner, 2018;Van den Berg et al., 2020;Wen et al., 2023).
Regarding the course content of cabin crew aero medicine and first aid training, article 121.419 of Ministry (2005) requires the crew members to be able to deal with abnormal conditions such as illness and injury of passengers or crew members, including being familiar with emergency medical equipment.The national vocational skill standard for civil aviation cabin crew of China describes in detail the in-flight first aid duties of cabin crew at all levels, as well as the specific skills and knowledge cabin crew need to obtain to handle medical problems.Meanwhile, the guidelines issued by the Federal Aviation Administration (FAA), Aerospace Medical Association (AsMA), Air Transport Medicine Committee, and International Civil Aviation Organisation (ICAO) recommend that every aircraft should have emergency medical kits and AED.Also, the crew members who are involved in each flight should be certified in accordance with the syllabus of basic life support (BLS).Based on those documents and the interview data, six categories have been identified related to course content in this study, which are medical emergency equipment, serious medical emergencies, minor medical problems, basic knowledge of in-flight first aid, mental health first aid and effective communication with Med-air.Moreover, those sub-categories have been updated according to the current COVID-19 situation, and the review of the most common medical problems happened onboard (Chandra & Conry, 2013;Intas et al., 2021;Kim et al., 2017;Kodama et al., 2018;Paxinos et al., 2021;Valani et al., 2010).Surprisingly, the finding shows that most of the airplanes owned by airlines in China fail to carry AED onboard, and just a few airlines include AED in their first aid training.AED usage is considered essential to improving sudden cardiac arrest outcomes (Hallstrom et al., 2004;Sanna et al., 2008) and is a vital part of CPR education (Reder & Quan, 2003).The good point is that during the COVID-19 and post-pandemic period, the supplementary IP kit has been added onboard with sufficient IPC.Supplies include masks, non-contact infrared thermometers, alcohol and disinfectant wipes, and hand sanitiser.The corresponding inflight IP training has also been conducted for cabin crew in different airlines in China.Apart from panic attacks, cabin crew aero medicine and first aid training have not covered mental health first aid.Mental health first aid refers to a skills-based training course that teaches participants to identify, understand and respond to mental health and substance use.It can help individuals to understand mental illnesses, support timely intervention, and save lives.The instructors and lecturers believe that it is necessary for cabin crew to know someone who is experiencing a mental health problem, whether that is a passenger or colleague, and the basic knowledge and skills on mental health first aid should be added to cabin crew aero medicine and first aid training.Previous studies highlighted the importance of ground medical assistance centres such as MedAire (Intas et al., 2021;Sigurdsson, 2017).However, we discovered that this medical support centre is unavailable for airlines in China, and relevant training must also be provided.Ground medical assistance is essential, especially for long-haul flights.The training for cabin crew to effectively communicate with them is suggested so that cabin crew can express the information well, get more professional support and render better first aid onboard.
Furthermore, the findings indicate the preference of cabin crew in China for learning aero medicine and first aid.Most of the participants prefer active learning to passive learning.Problem-based learning like group discussion, simulation-based learning using the simulator and virtual reality(VR), and blended learning are practical and effective learning approaches that can also attract learners' attention and make the course more interesting.When comparing our results to those of recent studies (Fariduddin et al., 2019;Federal Aviation Administration, 2009;Mahony et al., 2008;Winkelmann et al., 2016), it must be pointed out that traditional lecturing and classic case study are considered important methods for delivering aero medicine and first aid courses, which may be due to the learning habit which influences Chinese people for a long time.Blended learning has gained more popularity and has been widely used for its advantages, combining the best part of face-to-face learning and e-learning (Rasheed et al., 2020).As the participants mentioned, many e-learning modules have been developed and used for time-saving and improving training outcomes, mainly for large airlines in China.Moreover, it is suggested that the ratio of face-to-face and e-learning section need to be carefully considered due to the nature of first aid education because the learners need to get sufficient practice during face-to-face course, and their performance should be checked and evaluated by teachers in that point so that trainees can make the corresponding correction.Therefore, the face-to-face section should be more than the online section to achieve the ideal training goal.Nevertheless, this ratio can be adjusted according to the severity of COVID-19 during the post-pandemic period.For retention of first aid knowledge and skills, the finding aligns with previous studies indicating that repetition may be more critical days since last trained for skill and knowledge retention than changing certification frequency (Anderson et al., 2012).The data suggest that annual recurrent for cabin crew on aero medicine and first aid should be the minimum requirement instead of once every two years.The simulation of medical emergencies involving practical disposal mixed with other kinds of emergencies should be conducted in the simulator at the end of the year or sometime in a year by airline companies.Moreover, the findings also suggest cabin crew students in college or staff before joining airlines can get first aid education as early as possible and apply what they learned for real-world practice to accumulate practical experience and become increasingly proficient in this area.Overall, the results indicate that training cabin crew on aero medicine and first aid by adopting the proper combination of these strategies according to different course content would arouse the learners' interest and enhance the learning outcomes.

Practical implications
The results of this study can provide airlines in China with references for improving the current areo medicine and first aid training for cabin crew, as well as analyzing the existing shortfalls and initiating optimization plans.
First, the identification of these core competencies can be utilized as the appropriate criteria for designing effective cabin crew training programs based on CBE.Second, the cabin crew's in-flight first aid performance can be enhanced by clarifying the key factors that affect the cabin crew's first aid behaviors onboard.Airline companies need to pay attention to cabin crew fatigue and environmental constraints to protect both passengers and their employees.The junior cabin crew's initiative towards performing first aid onboard should be promoted properly.The sense of the cabin crew's mission needs to be strengthened.Third, new content has been identified for areo medicine and first aid training.A revised content that suit the need of the current medical emergencies and global public health can be proposed.Fourth, airlines in China need to investigate and upgrade their medical facilities onboard accordingly.Shortfalls regarding medical equipment, facilities onboard and insufficient recurrent training content in some airlines in China were revealed in this study.

Limitations
Several limitations need to be noted regarding the present study.Due to the qualitative nature of this study, when the data is extracted and interpreted, it is more dependent on the researchers' preconceptions and approach.Furthermore, this study adopted purposeful sampling alongside the snowballing technique.The non-probability sampling technique may lead to potential issues relating to the representativeness of the sample, even though the sample selected was managed to cover three layers of airlines in China, which achieved the study aim and saturation.Apart from that, the scope of this study is the airlines in China, and the participants are all from China, which may limit the generalizability of the research results to a certain degree since cabin crew and their instructors from different countries or regions may have different perspectives due to culture differences.Furthermore, airlines in different countries or regions may conduct aero medicine and first aid training differently, following principles or regulations adapted from IATA.

Conclusions
This is the first study using a qualitative approach to comprehensively investigate and understand the current situation of cabin crew aero medicine and first aid training in China.The findings indicated that airlines in China required their cabin crew to be trained in aero medicine and first aid during initial training and get the knowledge and skills refreshed during recurrent training so that they can be qualified for flying.Four themes related to cabin crew aero medicine and first aid training were generated through rigorous thematic analysis, covering 25 categories.Those themes are competencies required, factors that affect first aid behaviors, course content and instructional strategies.
The findings reported here shed new light on revising the current training programs and developing future aero medicine and first aid training modules for the post-pandemic period for the learners' diverse needs, experts' points of view, and training content that need to be updated have been figured out.Since the blended-learning mode is approved and suggested by all the participants as an practical and effective strategy with its flexibility, a blended-learning training module can be developed based on the findings of this study for training cabin crew on aero medicine and first aid for the post-pandemic period.This can also help preventing suspension of necessary training because of future possible medical crises.Moreover, this study pointed out the following shortfalls in the aspects of aero medicine and first aid, which need to be taken seriously by the management of the aviation industry, and take measures to improve gradually.First, some airlines conduct recurrent training once every two years, which is deemed insufficient for retaining knowledge and skills.Second, AED is crucial medical equipment for improving sudden cardiac arrest outcomes.However, most airplanes in China needed to be equipped with AED, and the usage of AED combined with CPR was not covered in cabin crew aero medicine and first aid training.Third, ground medical assistance centres like MedAire, which can provide professional and practical guidance for crews to handle medical emergencies when no doctor onboard, were unavailable for all airlines in China.
For future research, we suggest including international cabin crew from different airlines worldwide so that the findings can be generalized to other countries or airlines.Second, the effectiveness of different learning approaches based on the findings of this study can be further explored using mixed methods to optimize the cabin crew training programs.

First
were found among cabin crews' first aid affect, work-related hardiness and self-efficacy of first aid.Cabin crews' commitment dimension of work-related hardiness turned out to be positively related to self-efficacy of first aid.In addition, the results of the study also revealed that cabin crews' work commitment plays a mediating role between their first aid affect and self-efficacy of first aid.Xu et al. (2023).In-Flight Infection Prevention and Control Training for Cabin Crew in China: A Qualitative Study.In-flight IPC duties and training KAP Interview Purposive sampling Cabin crew IPC duties can be classified into four phases: before flight, passenger boarding, during flight, and after flight.The findings indicated airlines in China required their cabin crew to carry out strict IPC measures onboard throughout all stages of flight.Six major themes concerning cabin crew's in-flight IPC training were extracted: COVID-19 information, IPC Supplies and usage, IPC measures onboard, communication and explanation, information collection and report up, attitude and perceptions toward COVID-19, and IPC measures.Training for knowledge and technical skills was deemed comprehensive, non-technical skills such as communication and explanation were viewed as a weak link.Sigurdsson (2017).In-Flight Medical Emergencies-The Role of the Flight Crew and the Medical Professional.

Figure 1 .
Figure 1.Mapping of cabin crew aero medicine and first aid training.

Figure 2 .
Figure 2. Structure of cabin crew aero medicine and first aid training.

Table 1 . (Continued) Author/Title Research area Theory Methodology Result Yu
and Liang (2021).Relationships among affect, hardiness and selfefficacy in first aid provision by airline cabin crew.

Table 3 . Supportive quotes within theme one Theme One and supported statements Categories Theme One: Competencies required
"During COVID-19 and post-pandemic period, there are many extra duties regarding infection prevention for us, and there is a risk of getting infected.Even though, if we are cabin crew, we can't reject flying.Company needs us,and people need us.What we can do is to strictly stick to IPC measures."A2 Commitment to work and society(n=2)

Table 4 . Supportive quotes within theme two Theme Two and supported statements Categories Theme Two: Factors that affect first aid behaviors
(Wang, 2019)ill affect.What's else, fatigue?If we are too tired, it's hard to even notice who is getting sick.For early morning flights or overnight flights when I am lack of rest or exhausted, I will miss out on who's sick if the signs and symptoms are not obvious."A5"Whensomecabin crew are rendering first aid to passengers, others must control the crowd and prevent passengers from watching or recording the process.Otherwise, cabin crew will be nervous because of distraction and worrying about other things."A4,A6Wewillprovide first aid to help passengers for sure, as we are cabin crew.Even though passengers sometimes are demanding, we are still willing to help if they get sick or their lives are in danger."A4Perceivednorm(n=13)"Cabin crew are deemed to render first aid onboard, but a few of them tend to wait for others to do.If no one reacts, they will do it.Especially,somejuniorstend to wait for their purser or seniors to react."A15,A16Attitude(n=17) interview participants through her network and the recommendations of initial participants.The selection of participants must meet the following requirements:(1) The ratio of male and female is 2:8 since the ratio of male and female cabin crew in China is 24:76(Wang, 2019); (2) age groups should be less than 25 years old,26-30, 31-35, 36-40,41-45, above 46 years old;

Table 5 . Supportive quotes within theme three Theme three and supported statements Categories Theme Three: Course content
We learned heart disease, shock, infectious diseases like COVID.But, we are not professional medical personnel.We can't judge.CPR is what we can do most for the fatal medical case.I think it is the most important content we need to master for first aid training" A5 If there is no doctor onboard, the captain can contact the ground and decide if a diversion should be made to seek for help on the ground for airlines in China.There is no MedAire service in our airlines."A12 "Emirates and some other airlines have MedAire, which can guide the cabin crew to treat medical emergencies even though there is no doctor onboard.I think MedAire is a good backup rather than leaving the medical case to cabin crew alone if no doctor is onboard.What crew should master is how they can communicate with MedAire efficiently and follow their instructions."A13, A14 "Burn, nose bleeding, air sickness, abdominal pain, diarrhoea, fainting and hypoglycemia.Those are common diseases we can have onboard, and we need to know how to handle them properly" A8 Minor medical problems(n=13) "Basic knowledge of first aid, such as monitoring of vital signs, the basic principles of in-flight first aid, and procedure of implementation.Besides, it is necessary for cabin crew to understand the aviation environment and its effects on the human body."A17Basicknowledge of in-flight first aid (n=4)"Apart from the panic attack, more attention should be paid to other mental health problems as well.It is closely related to cabin safety."A16Mentalhealth first aid(n=3) "

Table 6 . Supportive quotes within theme four Theme four and supported statements Categories
"Our company has been using blended learning since I joined.I absolutely agree with this way, and I think it's good for us to review and reflect.For online courses, it can include everything.And face-toface section for CPR, trauma, and simulation."A11 "There is no online course for first aid.We got trained face-to-face for initial training and recurrent for first aid.I think the training is very intense, a lot of medical knowledge to learn or refresh."A1 Blended-learning(n=17) "Our company requires us to recurrent first aid twice a year.I feel like I forget most of what I have learned.If there is trauma happening onboard, I am not confident to handle it at all.Already forget the techniques I've learned before."A8 Regular repetition (n=12)