Strategies and goals of community-based injury prevention programmes--a mixed-methods study of 25 Scandinavian WHO Safe Communities

Documentation and analysis of prevention goals and interventions employed by community-based injury prevention programmes is vital to advance the knowledge and understanding of synergistic multi-strategy injury prevention programmes. This study examined the goals and interventions of 25 Scandinavian community-based injury prevention programmes in WHO-designated Safe Communities. Collection and analysis of quantitative data from survey questionnaires to the programme coordinators was followed by collection and analysis of qualitative data from structured interviews with programme coordinators from eight of the programmes. The results demonstrated that the programmes under study predominantly relied on "intuitive" and subjective methods for selecting interventions. The programmes largely failed to transform injury surveillance data into information and knowledge that could prioritize community safety strategies and measures, due to insufficient time and personnel resources. The results demonstrated the importance of combining passive approaches with active interventions. Educational efforts were considered essential to the programmes. The programmes preferred to rely on broadly stated goals rather than specific objectives.     

Strategies and goals of community-based injury prevention programmes – a mixed-methods study of 25 Scandinavian WHO Safe Communities

Documentation and analysis of prevention goals and interventions employed by community-based injury prevention programmes is vital to advance the knowledge and understanding of synergistic multi-strategy injury prevention programmes. This study examined the goals and interventions of 25 Scandinavian community-based injury prevention programmes in WHO-designated Safe Communities. Collection and analysis of quantitative data from survey questionnaires to the programme coordinators was followed by collection and analysis of qualitative data from structured interviews with programme coordinators from eight of the programmes. The results demonstrated that the programmes under study predominantly relied on ‘intuitive’ and subjective methods for selecting interventions. The programmes largely failed to transform injury surveillance data into information and knowledge that could prioritize community safety strategies and measures, due to insufficient time and personnel resources. The results demonstrated the importance of combining passive approaches with active interventions. Educational efforts were considered essential to the programmes. The programmes preferred to rely on broadly stated goals rather than specific objectives.     

Safe community in different settings

This paper describes the Safe Community concept and how communities aspired to safety through a structured, collaborative approach rather than a community that is already perfectly safe. The Safe Community movement started in Sweden at the end of the 1980s and was based on community-based injury prevention activities. Safe Communities are the communities that meet a set of 12 criteria (later changed to six indicators) set out by the WHO Collaborating Centre (WHO CC) on Community Safety Promotion at Karolinska Institutet in Stockholm. The communities may apply to the WHO CC to be designated as an official member of the WHO International Safe Community Network. To date, 83 communities around the world have been designated as members of the Safe Community Network, ranging in population from 1000 to nearly 2 million. Lidkj?ping in Sweden was the first designated safe community in 1989 and Rapla in Estonia was the last, designated in October 2004. The movement recognizes that it is the people who not only live, learn, work and play in a community but also best understand their community's specific problems, needs, assets and capacities. Their involvement and commitment are critical factors in identifying and mobilizing resources so as to create an effective, comprehensive and coordinated community-based action on unintentional and intentional injuries.     

Evaluation of community-based injury prevention programmes: methodological issues and challenges

The evaluation of comprehensive community-based injury prevention programmes is complex and poses many methodological challenges. There is little consensus in contemporary literature about the most appropriate methods of evaluating these programmes. This study employed a systematic literature review to examine evaluations of 16 community-based injury prevention programmes with regard to key methodological issues and challenges. Three aspects of the evaluated programmes were analysed: assessed elements (context, structure, process, impact, and outcome); study design; and methodological issues addressed. The results showed that context, structure and process assessments were the most neglected aspects of the evaluation studies. The programmes were typically described with minimal discussion of how the context may have influenced the effectiveness. The process (activities) was described rather than evaluated against appropriate standards of comparisons. Impact evaluations adhered more closely to documented guidelines, but half of the evaluations did not include impact variables. Outcome evaluations focused on injury incidence. Most evaluations employed some qualitative methods, but the vast majority of methods used were quantitative. This study indicated that the quasi-experimental study design has become an accepted norm for the evaluation of community-based injury prevention programmes. Most of the evaluations contained explicit details of the methodology used and of the choices related to the methodology. While threats to internal validity were identified in most studies, problems related to external validity and construct validity were largely overlooked by the evaluators.     

Motala Municipality - a sustainable Safe Community in Sweden

An extensive research project concerning injury prevention was planned and initiated in Motala Municipality in the early 1980s. This article summarises 25 years of work for injury prevention and safety promotion in Motala. Evaluation of both process and effect were conducted based on a quasi-experimental study design, as well as cost-effectiveness and cost-benefit analyses of interventions. Initial evaluations results showed an annual incidence of injuries of 118.9/1000 citizens in 1983/1984 consisting of injuries at home (35%), sports injuries (18.9%), injuries at work (13.7%), traffic-related injuries (12.8%) and other injuries (19.5%). The annual social economic costs of injuries were estimated at 116 million Swedish crowns (SEK). By 1989, after two years of preventive work, the incidence of injuries was reduced by 13%. The greatest decrease was among the moderate severity category of injuries (41%). The social economic costs were thereby reduced by 21 million SEK per year. Since then, work with injury prevention has continued and annual evaluations have shown that the incidence of injuries, with some fluctuation, has continued to decrease up to the latest evaluation in 2008. The total decrease during the study period was 37%. This study shows that community-based injury prevention work according to the Safe Community model is a successful and cost-effective way of reducing injuries in the local community.     

Impact of the Safe Community program in Harstad on the incidence of injuries

Objectives Since 1987, the Harstad community in Norway has run an injury prevention program according to the Safe Community approach. The effectiveness of this approach in reducing injury rates is poorly documented. The aim of this study was to evaluate the impact of the Harstad program on the incidence of injuries. Methods We used data from the National Injury register of Norway and compared age-adjusted incidence rates and standardized rate ratios of injuries in Harstad and three control communities for the period 1992-1997. Results Harstad had the second highest rates for both all injuries and fractures. No reduction in the incidence of injuries in Harstad was observed from 1992-1997. The injury rates in 1992-1997 were similar to the rates recorded in 1985/86. Conclusions The injury prevention program in Harstad has not reduced overall injury rates. The Safe Community concept is an organizational strategy, but implementation of proven and targeted risk reduction measures will be needed if community-based programs are to result in risk reductions.     

Evaluation of a home injury prevention program in a WHO Safe Community

The objective of this study was to evaluate the effect of a community-based injury prevention program on home injuries. Unintentional injuries occurring in private homes and during leisure time account for 70-80% of injuries treated in public health care. A quasiexperimental design was used for the study, with cross-sectional preand post-implementation measurements in the program area and in a neighboring control community. Children and the elderly were two main target groups of the intervention program, which was based on a participative strategy for community involvement. The study was based on defined total populations. The total relative risk for home injury occurrence decreased in the study area, whereas it increased in the control area. Regarding age and gender, there was a decrease for females and males in the study area and a slight increase in the control area. For males, the youngest and oldest age groups showed no decrease, whereas females showed a decrease among the youngest and those aged 60-79. No decrease was observed in the control area. The study showed that the Safe Community approach had a general effect on the incidence of home injuries.     

An investigation on knowledge-attitude-practice about injury and the related factors among school children's parents in Jinan, China

The aim of this study was to investigate the knowledge-attitude-practice (KAP) and their related factors on injury prevention and safety promotion among children's parents in the city area, in order to provide scientific data for the development of Safe School in mainland China. A total of 3617 subjects were investigated in Jinan with the help of a self-administered questionnaire which included parental demographic characteristics and 40 questions related to KAP about injury prevention and safety promotion. Responses to each question included only one correct answer. A score of 1 was given if the participant answered correctly, otherwise the score was 0. Therefore, the total KAP score was 40 if all the 40 questions were answered correctly by one respondent. The total KAP scores were classified into two categories for which the cutoff value was the mean of the total KAP scores. The results showed that the KAP scores ranged from 13 to 39, with an average of 30.79?±?3.54. Higher KAP scores were statistically associated with mothers (odds ratio [OR]?=?1.79) and higher education level (OR?=?1.34). It was concluded that parental KAP about injury prevention and safety promotion was unsatisfactory, and health education on KAP about injury prevention and safety promotion for parents, especially among fathers and parents with low education levels, should be strengthened further by Safe School programmes.     

Uncovering evidence on community-based injury prevention: A review of programme effectiveness and factors influencing effectiveness

This study examines systematic reviews of community-based injury prevention programmes to obtain an overview of the evidence base on the effectiveness of these programmes and to analyse how effectiveness is measured and the extent to which factors contributing to achieving programme effectiveness are examined in these reviews. Thirteen systematic reviews were found, encompassing a total of 121 programmes. The results reinforced the well-documented point that the evidence regarding the effectiveness of community-based injury prevention programmes is inconsistent. Some of the programmes targeting specific injury categories, e.g. specific injury types and/or age groups, were successful, whilst more broadly targeted programmes demonstrated less convincing results. Effectiveness was predominantly measured as injury rate reductions. Only one of the reviews identified contextual factors that could have impacted on programme effectiveness. To advance the field, researchers and systematic reviews need to include evidence on factors that may explain how the effects were achieved.     

Statistical considerations for the design,conduct and analysis of the efficacy of safe community interventions

In injury research, the use of community-level intervention trials is quite common. Often, it is the only practical method for assessing the efficacy of countermeasures or preventive interventions. ‘Safe Community’ is an intervention concept aimed at establishing community-level programs and policies to ensure the safety of inhabitants in a community. The methodological considerations in evaluating the efficacy of such interventions need to be well understood by injury researchers and policy makers. This paper presents various statistical issues that need to be considered in the design, conduct and analyses of community-level intervention trials. Only with an understanding of the statistical issues will such studies have the appropriate design, conduct and analysis, and thus be appropriately well-received, with the implication that they will indeed help to build safer communities.     

Roles of a hospital for community safety promotion

It is not easy for any health professional to be aware of injury problems and safety issues within their own communities if their main responsibility is not in this field. Health professionals, however, can play an important role in all aspects of injury prevention and safety promotion. This includes not only medical or surgical treatment for the injured patients but also risk assessment, health education, community action, organisational development and advocacy for policy to promote safety at a multi-level in the society. This can be accomplished most efficiently through collaboration with diverse sectors within a community, including hospitals, public health professionals, policy makers, school boards, police departments, fire departments, citizens' coalitions and others. Since 2002, Ajou University School of Medicine and Public Health in Suwon, Korea, has introduced a Safe Community model to many countries in Asia, including Korea, Japan, China, Vietnam, Thailand, among others, which is led by The World Health Organization Collaborating Centre on Community Safety Promotion at Karolinska Institutet, Stockholm, Sweden.     

Child injury prevention in Vietnam: achievements and challenges

As with other South Asian countries, injury is becoming a leading cause of death and morbidity among children in Vietnam. In response to the increasing burden of child injury, government and non-government agencies in Vietnam have combined efforts during the last decade to develop and implement various child injury prevention strategies and programmes. This article provides, through a review of relevant documents and interviews with major stakeholders, an overview of these efforts and highlights major challenges to child injury prevention in the country. The findings point to notable achievements in terms of increasing awareness of injury facing children at all levels in the community and developing a sound injury prevention policy framework in a relatively short period of time. However, much needs to be done to implement necessary environmental and legislative changes, strengthen child injury surveillance and injury prevention research; and to improve access to health services. The insight into the experience of Vietnam could benefit other low- and middle-income countries with a high burden of child injury.     

Child injury prevention in Vietnam: achievements and challenges

As with other South Asian countries, injury is becoming a leading cause of death and morbidity among children in Vietnam. In response to the increasing burden of child injury, government and non-government agencies in Vietnam have combined efforts during the last decade to develop and implement various child injury prevention strategies and programmes. This article provides, through a review of relevant documents and interviews with major stakeholders, an overview of these efforts and highlights major challenges to child injury prevention in the country. The findings point to notable achievements in terms of increasing awareness of injury facing children at all levels in the community and developing a sound injury prevention policy framework in a relatively short period of time. However, much needs to be done to implement necessary environmental and legislative changes, strengthen child injury surveillance and injury prevention research; and to improve access to health services. The insight into the experience of Vietnam could benefit other low- and middle-income countries with a high burden of child injury.     

Economic analysis of injury prevention--applying results and methodologies from cost-of-injury studies

Injuries pose an economic problem of immense proportion to communities in every society. The economic burden from injuries can be quantified through cost-of-injury studies, using techniques adopted from cost-of-illness research. This study explores the feasibility of applying results and methodologies from existing cost-of-injury studies in economic analyses of injury prevention interventions and programmes. The literature on cost-of-injury studies and economic appraisals of injury prevention efforts was examined to elicit studies that calculated injury costs. Studies were accepted for inclusion if they included an analysis of the costs of all injuries occurring in a geographical area (community, region or country) during a specific time period, employed a societal perspective and an incidence-based costing approach and were conducted in industrialized countries. There were 12 studies that met the inclusion criteria. The average total cost per injury case was USD $3536, while the average share of indirect to total cost per injury case was 71%. However, the cost figures showed wide variation across the studies. Based on the limited similarity of findings from the studies, it was concluded that it is not feasible to apply results and methodologies from existing cost-of-injury studies. The cost estimators described in this study could possibly be adapted for use as reference points in economic analyses of existing programmes, but any other uses should be approached with caution. Locally obtained data are needed for reliable economic analyses of injury prevention interventions and programmes.     

Estimating population-based injury prevention practices

This study piloted a survey suitable to generate statewide prevalence estimates for injury prevention practices and/or behaviours. A number of prevalence estimates of injury prevention practices and/or behaviours were generated in the pilot. For example, the prevalence of a household smoke alarm was high (732/1000 households) and yet only 44% of households had tested the functionality of the alarm in the 12 months preceding the survey. Findings of this kind point to an increasing need for primary care practitioners to play a leading role in targeting preventive strategies for injury. In addition, the survey methods and approach highlight the value of such information to health departments and non-government agencies in terms of targeting priority injury risk behaviours and the evaluation of injury-related intervention programmes. The survey has been designed so the methods can be applied nationally and internationally.     

Rapid assessment procedures in injury control

Injuries are among the leading causes of death and disability worldwide. The burden caused by injuries is even greater among the poorer nations and is projected to increase. Very often the lack of technical and financial resources, as well as the urgency of the problem, preclude applying sophisticated surveillance and research methods for generating relevant information to develop effective interventions. In these settings, it is necessary to consider more rapid and less costly methods in applying the public health approach to the problem of injury prevention and control. Rapid Assessment Procedures (RAP), developed within the fields of epidemiology, anthropology and health administration, can provide valid information in a manner that is quicker, simpler, and less costly than standard data collection methods. RAP have been applied widely and successfully to infectious and chronic disease issues, but have not been used extensively, if at all, as tools in injury control. This paper describes Rapid Assessment Procedures that (1) are useful for understanding the scope of the problem and for identifying potential risk factors, (2) can assist practitioners in determining intervention priorities, (3) can provide in-depth knowledge about a specific injury-related problem, and (4) can be used in surveillance systems to monitor outcomes. Finally, the paper describes some of the caveats in using RAP.     

Economic analysis of injury prevention – applying results and methodologies from cost-of-injury studies

Injuries pose an economic problem of immense proportion to communities in every society. The economic burden from injuries can be quantified through cost-of-injury studies, using techniques adopted from cost-of-illness research. This study explores the feasibility of applying results and methodologies from existing cost-of-injury studies in economic analyses of injury prevention interventions and programmes.

The literature on cost-of-injury studies and economic appraisals of injury prevention efforts was examined to elicit studies that calculated injury costs. Studies were accepted for inclusion if they included an analysis of the costs of all injuries occurring in a geographical area (community, region or country) during a specific time period, employed a societal perspective and an incidence-based costing approach and were conducted in industrialized countries. There were 12 studies that met the inclusion criteria.

The average total cost per injury case was US$3536, while the average share of indirect to total cost per injury case was 71%. However, the cost figures showed wide variation across the studies. Based on the limited similarity of findings from the studies, it was concluded that it is not feasible to apply results and methodologies from existing cost-of-injury studies. The cost estimators described in this study could possibly be adapted for use as reference points in economic analyses of existing programmes, but any other uses should be approached with caution. Locally obtained data are needed for reliable economic analyses of injury prevention interventions and programmes.     

The establishment of injury surveillance in Thailand

The Provincial Injury Surveillance System was initiated in Thailand in 1993 to establish a database for assessment of the quality of acute care and referral services provided to the injured at the provincial level, and to facilitate injury prevention and control at both local and national levels. An injury surveillance system model that adopted a trauma registry as the record form, was established in five selected large hospitals, one from Bangkok and four from major regions of Thailand. Data analysis was undertaken and utilized at both local and national levels. The Epidemiology Division of the Ministry of Public Health supervised and assessed the data quality. Evaluators from the School of Public Health identified problems in operating the system at the provincial level and assessed the feasibility of expanding the project. The data of 66,895 injuries including 1,755 deaths reported in 1995; revealed fundamental problems in the emergency medical services. Causes of major injuries were identified and their epidemiology described. The coverage of reporting was over 90%. The completeness and reliability of recording ranged from 80.6–100%. This model of sentinel surveillance is appropriate for injury problems, which are of large magnitude and are at the early phase of problem solving. Development of the information systems administration and human resource in computer technology are necessary to cope with the problems of increased workload in data collecting and processing. This model of surveillance is feasible for expansion but its data system has to be appropriately integrated into the existing systems of the hospitals.     

The mortuary as a source of injury data: progress towards a mortuary data guideline for fatal injury surveillance

To help bridge the obstacle of inadequate injury fatality data in low and medium income countries (LMICs) a simple cost effective system for mortuary surveillance of fatal injuries is being developed in consultation with the WHO. This will inform, direct and monitor injury prevention (IP) interventions and policies in LMICs. This article uses CDC's 'attributes of a successful surveillance system' to describe the process, the barriers and solutions in development of this mortuary data guideline. The consultative process utilised generated feedback from key stakeholders including forensic pathologists, Ministry of Health officials and injury prevention experts. An International Advisory Group was also convened to guide the guideline development. These assisted the adjustment of the proposed guideline to maximise flexibility, acceptability and stability; whilst minimising resource implications. Representativeness and the securing of government support perhaps remain the most significant challenges. Consultation with the advisory group and the wider stakeholders has been effective in developing a widely acceptable, user-friendly, low resource data form to gather useful data. Further strategies to overcome barriers need to be developed over the course of the pilot study and this should be done in consultation with the advisory group and stakeholders.     

An epidemiological study of injury in a low socioeconomic context: implications for prevention

Epidemiological information identifying injury magnitude and risks is vital for the development of prevention and safety promotion programmes, especially for low income, marginalised communities where the incidence of injury tends to be disproportionately high. This paper, accordingly, reports on a household survey, conducted in an informal settlement southwest of Johannesburg, South Africa, and designed to gather epidemiological data for the purposes of informing the development of appropriate community-based injury prevention and safety promotion programmes. Data were collected for a one-year period prior to October 1998. An analysis of the data identified the causes of injuries, which residents were most at risk, and where and when injuries most often occurred. By way of conclusion, we make a few recommendations for preventive measures.