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  1. 1. HEALTH PROMOTION INTERNATIONAL Vol. 17, No. 3© Oxford University Press 2002. All rights reserved Printed in Great BritainCommunity-based childhood injury preventioninterventions: what works?ELIZABETH TOWNER and THERESE DOWSWELLCommunity Child Health, Department of Child Health, University of Newcastle upon Tyne, DonaldCourt House, 13 Walker Terrace, Gateshead NE8 1EB, UKSUMMARYUnintentional injury, with its broad range of injury types, programme was, and the strength of the evidence, ispossible countermeasures, and great number of agencies summarized in tabular form. There is increasing evidenceinvolved in its prevention, lends itself to community- emerging about the effectiveness of community-basedbased approaches. In this paper we examine 10 community- approaches in injury prevention. Important elements ofbased injury prevention programmes that have targeted such approaches are long-term strategy, effective focusedchildhood injury prevention and have been evaluated using leadership, multi-agency collaboration, tailoring to thesome measure of outcome. We investigate the nature of needs of the local community, the use of local injurythe intervention, targeting, the length of programmes and surveillance, and time to coordinate existing and developmulti-agency involvement. We also consider how the pro- new local networks. We recommend that there is a needgrammes have been evaluated, and what outcome, impact to develop indicators to assess and monitor a culture ofand process measures have been used. The information on safety, programme sustainability and long-term communitythe intervention and how it was evaluated, how effective the involvement.Key words: children; community-based programmes; systematic reviews; unintentional injury preventionINTRODUCTIONIn recent years, health promotion has attempted and the large number of agencies involved in itsto address the complexity of many health prob- prevention, lends itself to community-basedlems by employing community-based approaches approaches.(Tones and Tilford, 1994). These represent a shift In this paper we examine community-basedin emphasis from an individual to a social injury prevention programmes that, eitherresponsibility for health (Finney et al., 1993) and wholly or in part, have targeted childhood injurystress the importance of multiple interventions, prevention, and have been evaluated using somewhich can complement and reinforce each other measures of outcome. We consider whether suchin particular geographical areas. Also embodied approaches have been effective and which com-within such approaches is a commitment to ponents work. We also discuss the implications foraddressing health inequalities and the need to give the development of interventions in the future andpeople more power over their lives. Community- how these can be evaluated.based approaches have been used and evaluatedin a number of health promotion fields, includingthe prevention of cardiovascular disease (Puska Unintentional injuryet al., 1989). Unintentional injury, with its broad Unintentional injury represents a significantrange of injury types, possible countermeasures public health problem in all higher income 273
  2. 2. 274 E. Towner and T. Dowswellcountries and an increasing number of lower (WHO, 1989). Since that time, an increasingincome countries (Manciaux and Romer, 1991) number of communities around the world havebut has, until recently, been neglected on both used community-based approaches in injurythe national and international agenda [World prevention and some of these programmes haveHealth Organization (WHO, 1996)]. Once over- been evaluated. Lessons learnt from suchshadowed by other causes of death and ill health, programmes would have direct application ininjuries have grown in relative importance as how best to develop, coordinate and evaluatemany diseases have been controlled. In England, injury prevention programmes at a local level.unintentional injury is the main cause of death in Very few community-based prevention pro-children and young people, is a major cause of grammes have been evaluated until recently.ill health and disability, is responsible for con-siderable financial and psychological costs andis strongly linked with social deprivation. Itsimportance as a major public health problem has METHODSbeen recognized by its inclusion as a target in‘Saving Lives: Our Healthier Nation’, England’s This paper uses as its source a systematic reviewPublic Health Strategy document (Secretary of of the literature, which seeks to answer theState for Health, 1999). question ‘how effective are health promotion There is a wide range of possible counter- interventions in preventing unintentional injuriesmeasures available for unintentional injury, but in childhood and young adolescents?’ (Townerrelatively few measures have been implemented et al., 2001). This source review has built on andat a community-wide level. There has been a revised three earlier reviews published in 1993longstanding debate within the injury field about (Towner et al., 1993) and 1996 (Nuffield Institutethe relative importance of ‘passive’ environmental for Health and NHS Centre for Reviews andor engineering solutions (e.g. traffic calming, Dissemination, 1996; Towner et al., 1996). Itproduct design, playground modification) versus includes 155 studies or groups of studies published‘active’ behavioural solutions (e.g. pedestrian between 1993 and 1996. Of these 155 studies, 10skills training, promotion of cycle helmet were included that evaluated community-basedwearing). The community-based approach to injury prevention programmes. We are particularlyinjury prevention offers the opportunity to interested in those programmes that targetedstimulate ‘a process of cultural change which childhood injury.allows an optimal mix of environmental and In the source systematic review, the relevantbehavioural solutions to be put into place’ literature was identified by a variety of means.(Moller, 1992). Changes in behaviour may occur Computerized databases including MEDLINE,at the whole community level through net- BIDS (and more recently the Web of Science)working, mutual support and beyond this to and Excerpta Medica, and more specializedcooperative advocacy for local policy changes. A sources such as the Transport and Roadcoordinated approach by a range of agencies is Laboratory (TRL) database were searched (aan essential ingredient: thus, injury prevention is full list of databases searched and search termsless divided by sectoral allegiances and a common used is available on request). This electronicculture of safety allows the adoption of comple- search was supplemented by hand searching amentary solutions, which should enable a number of key journals such as Accident Analysismultiplier effect to be achieved (Moller, 1992). and Prevention and Injury Prevention, along The philosophy behind community develop- with the reference lists of relevant publishedment set out in the Ottawa Charter for Health articles and books. In addition, key informantsPromotion incorporated a concern with reducing (researchers and specialists in the area of childinequalities and promoting ownership of health- injury prevention) were consulted. The criteriarelated issues (WHO, 1986). This broad concept for the inclusion of studies were as follows.of safety promotion was developed in relation toinjury prevention in the mid 1970s by workers (i) They were written in English and publishedat the Karolinska Institute in Sweden. The between 1975 and 2000 (the last search wasManifesto for Safe Communities was set out at carried out in June 2000).the First World Conference on Accident and (ii) They related to the prevention ofInjury Prevention held in Sweden in 1989 unintentional injuries (solely or in part).
  3. 3. Community childhood injury prevention: what works? 275(iii) The target population included children A total of 15 evaluated studies were identified 15 years old and results were reported for that related to community-based studies. Five of this group. the programmes used a simple before–after(iv) They described either a primary interven- design, with no control group, and three of these tion measure to prevent accidents occurring provided very few details of the intervention or or a secondary measure to prevent or reduce evaluation. We thus excluded five studies from the severity of injuries. the paper (Tellnes, 1985; Robertson, 1986; Sahlin(v) They had been evaluated using some meas- and Lereim, 1990; Jeffs et al., 1993; Lindquist et ure of outcome or impact. These included al., 1998). This paper examines the remaining changes in injury mortality or morbidity, 10 programmes in more detail. changes in observed or reported behaviour, In the Results, we describe the 10 programmes environmental change or hazard removal, or identified: the features of the intervention, the changes in knowledge or attitudes. groups or communities they target, the outcome, and process measures used in the evaluation.Violence prevention studies were excluded, We then discuss injury surveillance systems,except in those cases where they were combined examine how intervention and control com-with unintentional injury studies. munities have been chosen, and examine which All studies were read and reviewed independ- process measures have been employed.ently by two reviewers. Where statistical adviceor other specialized knowledge was required athird reviewer was consulted. A standardized RESULTSdata extraction form was devised and used torecord details from each study included (avail- Interventionable on request). Details recorded included the The 10 programmes are summarized in Table 1:date and place of the study, the injury target (Schelp, 1987; Svanström et al., 1996) (1); (Guyergroup, and the aim, content and setting of the et al., 1989) (2); (Schwarz et al., 1993) (3);intervention. Where interventions had been (Davidson et al., 1994; Kuhn et al., 1994) (4);targeted at socially or economically disadvantaged (Hennessey et al., 1994; Ozanne-Smith et al.,groups this was noted. In addition, details about 1994) (5); (Ytterstad, 1995; Ytterstad andthe evaluation were recorded. This included a Sogaard, 1995; Ytterstad and Wasmuth, 1995;brief description of the methods used (the study Ytterstad et al., 1998) (6); (Svanström et al., 1995)design, sample size, data collection methods, (7); (Day et al., 1997) (8); (Petridou et al., 1997)outcome, impact and process measures). In (9); and (Coggan et al., 1998; Coggan et al., 2000)particular, we were keen to assess how the inter- (10).vention and control groups were selected and Six out of the 10 programmes are based on thehow comparable these groups were. A note was WHO Safe Communities Model, initiallyalso made of strengths and weaknesses of the developed in the community of Falköping inevaluation. The British National Health Service’s Sweden (study 1). This model combines twoCentre for Reviews and Dissemination guide- elements: community diagnosis, which relies on alines on carrying out systematic literature reviews local surveillance system to provide an accurate(Arblaster et al., 1995) were consulted for picture of the local injury problem, and ainformation regarding the process of assessing reference group to coordinate activities. The sixthe quality of the evidence of the various studies. programmes took place in Scandinavia, AustraliaThe reviewers reached a consensus decision on and New Zealand (Table 1: studies 1, 5, 6, 7, 8the quality of the evidence. Each study was and 10). Of the remaining projects, three weregraded on a five-point scale ranging from weak conducted in the United States (2, 3 and 4) andto good (i.e. weak, reasonable/weak, reasonable, one in Greece (9).reasonable/good, good). Key results were recordedand a consensus decision was made about theeffectiveness of the intervention. Details from Targetingthe data extraction forms were used to devise Five of the six programmes based on the Safesummary tables for each study included. At this Communities Model have targeted a range ofstage, those studies where the evidence was rated ages (except study 6). The Shire of Bulla Safeas weak were excluded. Living Program (study 5), for example, targeted all
  4. 4. Table 1: Community-based injury prevention programmes 276Author, date and Injury target group Aims and content of Study type and Outcome impact and Key resultscountry and setting intervention sample size process measures1a. (Schelp, 1987) Home and Falköping Accident Prevention Controlled trial (i) Deaths (a) Reduction of 27% in home1b. (Svanström et al., occupational injuries Programme (a) I = Falköping (ii) Hospital admissions accidents and 28% in occupational 1996) Sweden targeted Based on community diagnosis C = Lidköping (iii) Accident and accidents Children and older and use of reference group to (b) I = Falköping Emergency attendance Effective people coordinate activities (pop. 32 022) (a) 1979–1982 (b) Hospital admissions increased by Education of policy makers and C1 = Skaraborg County (b) 1983–1991 8.7% (females) and 4.9% (males) health workers (pop. 277 397) in I. Smaller increases in C1 and C2 Range of interventions C2 = Sweden Ineffective therefore inconclusive (pop. 8 644 125) overall Reasonable/weak evidence E. Towner and T. Dowswell2. (Guyer et al., 1989) Children under Statewide Child Injury Controlled trial (i) Accident and (i) Reduction in passenger motor vehicle USA 5 years Prevention Program (SCIPP) I = nine communities Emergency attendance injuries in I compared with C Health promotion campaigns (pop. 139 810) (ii) Reported behaviour No evidence found in the reduction related to burns, poisoning, falls, C = five communities (iii) Knowledge of other target injuries suffocations and passenger (pop. 146 866) (ii) Exposure to prevention messages motor vehicle injuries associated with safety behaviour (iii) 42% of households with children in I exposed to one or more interventions Partially effective Good evidence3. (Schwarz et al., 1993) General population Safe Block Project Controlled trial (i) Observation of hazards (i) Intervention homes significantly USA Focus on urban In poor inner city community I = census tracts in (ii) Knowledge more likely to have Ipecac and African–American Community workers and Philadelphia, 3004 (iii) Community smoke detectors (minimal– population community representatives homes involvement moderate effort), but fewer involved in home inspections C = census tracts in differences for home hazards and educational programme Philadelphia, 1060 requiring major effort Focus on falls, fires, scald burns, homes (ii) Distinct difference between I and poisonings and violence C houses in safety knowledge (iii) Community representatives recruited for 88% of blocks Partially effective Good/reasonable evidence4a. (Davidson et al., Children aged Safe Kids/Healthy Controlled trial (i) Deaths (i) Significant reductions in injuries in 1994) 5–16 years Neighborhoods Injury I = Central Harlem (ii) Hospital admissions I and C areas4b. (Kuhn et al., 1994) Disadvantaged Prevention Program Pop. of children 17 years (iii) Participation in study In I, 44% reduction in targeted USA community Coalition of organizations = 28 457 injuries aimed to reduce outdoor injuries C = Washington Heights In I, decline specific to targeted in children and reduction of Pop. of children 17 years injuries assaults to children = 66 305 (iii) 10 000 children participated in Involved playground specific programmes renovation, safety equipment, Partially effective/inconclusive supervised activities and Reasonable evidence education (26 organizations)
  5. 5. Table 1: continuedAuthor, date and Injury target group Aims and content of Study type and Outcome impact and Key resultscountry and setting intervention sample size process measures5a. (Ozanne-Smith et al., 1994) All ages Shire of Bulla Safe Living Controlled trial (i) Mortality and (i) Little evidence of reduction of5b. (Hennessey et al., 1994) All injury types Program I = Shire of Bulla morbidity data injury morbidity Australia Based on Falköping model and (pop. 28 347) (ii) Observed behaviour Some evidence for telephone injury surveillance C = Shire of Melton (iii) Area-wide survey of reduction in minor Aimed to prevent injuries, (pop. 28 812) environmental change injuries reduce hazards and increase (iv) Attitudes knowledge (ii) Increased use of safety devices public awareness and equipment—helmets, safety 113 preventive programmes, seats, smoke detectors with emphasis on training (iii) Hazard reduction ( 50% of professionals, environmental recommendations following modification, audit and playground safety audit enacted) advocacy (iv) Increased community awareness Partially effective Good evidence6a. (Ytterstad and Wasmuth, 1995) General population Harstad WHO Safe (a) Controlled trial (a) Mortality data (a) 27% reduction in overall traffic6b. (Ytterstad, 1995) but specific Community Programme I = Harstad Hospital admissions injury rate6c. (Ytterstad and Sogaard, 1995) components All ages, all injury types (pop. 22 000) A and E attendance Significant reduction for6d. (Ytterstad et al., 1998) targeted at children programme over a period of C = Trondheim Primary care 0–9 years and 15–24 years Norway Targeted at children 7–9 years (pop. 134 000) (b) Hospital admissions Partially effective/inconclusive 0–4 years of age (a, b) Targets included child (b) Before and after A and E attendance (b) 0–15 years—37% reduction in pedestrians and cyclists—infant study (c) Mortality data cyclist injuries and 54% car loan schemes, lobbying for I = Harstad Hospital admissions reduction in pedestrian cycle paths (pop. 22 000) A and E attendance injuries—decreased exposure (c) Burn prevention— C = Trondheim (d) Morbidity data Partially effective/inconclusive counselling, professional (pop. 134 000) Outpatient admissions awareness raising, safety devices (c) Controlled trial records (c) 53% reduction in burn injury (d) Burn prevention—cooker I = Harstad rates in I, 10% increase in C1 guards and lowering tap water (pop. 22 000) and 14% decrease in C2 thermostats C1 = Trondheim Admissions in I in later period Educational activities (pop. 134 000) less severe Programme focused on its own C2 = six towns around Effective sustainability Harstad (d) Decrease in burn injury rates at (pop. 14 000) 51.5% in I1, 40.1% in I2 and (d) Controlled trial increase of 18.1% in C I1 = Harstad Inconclusive (pop. 23 000) Reasonable evidence I2 = six towns around Harstad (pop. 14 000) C = Trondheim Community childhood injury prevention: what works? (pop. 134 000) 277
  6. 6. 278Table 1: continuedAuthor, date and Injury target group Aims and content of Study type and Outcome impact and Key resultscountry and setting intervention sample size process measures7. (Svanström et al., 1995) Children 0–14 years Lidköping Accident Prevention Controlled trial (i) Hospital discharge (i) From 1983 to 1991 a reported Sweden Programme I1 = Lidköping register data annual decrease in hospitalized Community-wide injury (pop. 35 949) (ii) Process data: notes injuries of 2.4% (boys) and prevention programme C1 = four surrounding and reports of health 2.1% (girls) in I1 (a) Surveillance of injuries municipalities (pop. planners In C1, increase in hospitalized (b) Provision of information 42 078) injuries of 0.6% (boys) and (c) Training C2 = Skarabourg county 2.2% (girls) E. Towner and T. Dowswell (d) Supervision (pop. 278 162) In C2, decrease of 1.0% (boys) (e) Environmental measures and 0.3% (girls) Specific activities—bicycle Inconclusive helmet campaigns, first aid Reasonable/weak evidence training for parents, loan schemes, removal of local hazards8. (Day et al., 1997) General population Latrobe Valley Better Health Before and after study (i) Emergency (i) Overall decline in rate of Australia Project (non-targeted injuries Department attendance from 6594 to All ages, community-based used for comparison presentations 4821/100 000 for targeted injuries, approach to prevent injuries, data) (ii) Self-reported injury compared with a small decrease reduce hazards and increase (a) Injury surveillance Knowledge in non-targeted injuries public awareness system (Victorian (iii) Playground hazards Significant decrease in (a) Home Injury Surveillance playground injuries among (b) Sports System) 5- to 14-year olds (c) Playground injuries, and (b) Telephone survey Estimated 908 injuries prevented (d) Alcohol misuse among youth 375 households pre- (ii) Telephone survey test, 400 households Non-significant decrease in rate Exhibition, home safety training, post-test of self-reported injuries from education for new mothers 62.7 to 48.2/1000. Non-significant Protective sports equipment increase in injuries requiring promoted medical attention from 24.5% Playground safety— to 31.9%. environmental measures Modest increases in knowledge Mass media and community (iii) Evidence of hazard removal in event playgrounds Process: 46 000 educational contacts with community on home injury prevention Evidence of institutionalization of programme Partially effective/inconclusive Reasonable/weak evidence
  7. 7. Table 1: continuedAuthor, date and Injury target group Aims and content of Study type and Outcome impact and Key resultscountry and setting intervention sample size process measures9. (Petridou et al., 1997) Young people Greek Island Community Injury Controlled trial (i) Self-reported injuries (i) No difference in accidents Greece 0–18 years Prevention Project I = Island of Naxos (ii) Observed hazards reported in I and C Older adults 65 years Multi-faceted intervention (172 households) Attitudes (ii) For I, improvements on 11 out involving local community C = Island of Spetses Knowledge of 28 hazard variables leaders and activities for parents, (177 households) (iii) Improvements in 1/28 hazard teachers and children variables (improvement related Home visits, counselling on to changes that could easily or home hazards cheaply be implemented) Partially effective Reasonable/weak evidence10a. (Coggan et al., 1998) General population Waitakere Community Injury Controlled trial (i) Injury rates (hospital (i) No significant reductions in10b. (Coggan et al., 2000) with specific Prevention Project (WCIPP) I = Waitakere admissions and census admissions overall in I, C1 New Zealand components targeted All ages, all injuries, prevention (pop. 155 000) data) in I, C1 and C2 and C2 at children 0–14 years programme based on WHO C1 = comparison (ii) Data from Land In children 0–14 years, decrease of age model. community Transport Safety in admissions in I, no decrease Multicultural urban Seven priority areas—Maori, (pop. = 147 000) Authority and Fire in C1 or C2 (sig) community Pacific, children, young people, C2 = rest of Auckland Service (ii) Land Transport data annual older people, alcohol and roads. (iii) Self-reported injury increase of 7% in adults Three approaches and appropriately restrained in front (a) Promotion (iv) Self-reported seats, 7% increase in children in (b) Education and awareness behaviour (telephone I (C1, not clear) (c) Advocacy and environmental survey n = 4000 in I (iii) No reduction in self-reported change and C1) injury in I and C1, but fewer (v) Reach/awareness in injured people required medical Range of activities including total population and treatment promotion of car restraints, cycle organizations (iv) Significant increases in helmets, smoke alarms, burn and ownership of child restraints, scald education pool fencing, stair gates and protective sports equipment in I compared with C1 (v) 85% of organizations in I aware of intervention compared with 25% in C1 Partially effective Good/reasonable evidencePop., population; I, intervention; C, control. Community childhood injury prevention: what works? 279
  8. 8. 280 E. Towner and T. Dowswellage groups and injuries occurring in home, school evaluation. For example, the recruitment ofand leisure environments. The three US studies representatives of neighbourhood housingtargeted children, and the Greek island study blocks was regarded as a measure of communitytargeted young people and older adults. The involvement in the Safe Block Project (study 3).Statewide Child Injury Prevention Program in The Waitakere Community Injury PreventionMassachusetts (study 2) selected the main injury Project was placed within local government: thistypes affecting pre-school children, for which provided the council with an avenue to interacta proven countermeasure was available, and with the voluntary sectors of the community andthus developed programmes aimed at the preven- ‘thereby contribute to the social structure oftion of burns, poisoning, falls, suffocations and Waitakere’ (study 10). The Safe Communitiespassenger road traffic accidents. Two programmes Model advocates the need for a reference groupspecifically targeted deprived communities: the to coordinate the activities of the agenciesSafe Block Project (study 3) in a poor African– involved in delivering the intervention. The NewAmerican inner city community in Philadelphia, Zealand project stressed the pivotal role ofand the Safe Kids/Healthy Neighborhoods Pro- project coordinators.gram (study 4), in a mainly non-Hispanic, blackcommunity in Harlem. One programme wasbased in a multi-cultural urban community Nature of the interventionin New Zealand (study 10) and had specific An innovative feature of many programmes wascommunity components for Maori and Pacific the attempt to deliver a range of diverse activitiespeople. at the same time. Unlike some health problems, the range of possible preventive activities is vast, and no intervention alone is likely to result inLength of intervention observable differences in the injury mortality orSome programmes had been in progress for morbidity experienced by a single community.many years. The Harstad programme (study 6) The Safe Kids/Healthy Neighborhoods Programfrom Norway developed over a period of 7–9 (study 4) aimed to reduce outdoor injuries inyears. The evaluation of the Shire of Bulla Safe children. Specific interventions included theLiving Program and the Waitakere Community renovation of playgrounds, the involvement ofInjury Prevention Project (studies 5 and 10, children and adolescents in safe supervisedrespectively) related to the first 3 years of longer activities, which taught them useful skills, theprojects. In contrast, the Greek island (study 9) provision of injury and violence preventionand the Safe Block Project (study 3) inter- education and the supply of safety equipment atventions were both of short duration. a reasonable cost. Several of the programmes included elements that resulted in environmental change, or lobbied for environmental change.Multi-agency approaches For example, lobbying for the provision ofA feature of most of the community-based cycle paths was a feature of the Harstad pro-programmes has been the involvement of a range gramme (study 6), and a parent pressure group inof organizations drawn from health, Local the Latrobe Valley Project (study 8) was active inAuthority, voluntary and commercial agencies. changing Council priorities with respect to theInterventions have taken place in a variety of refurbishment of existing playgrounds and thesettings: home, school, roads and neighbour- creation of new ones. The scale of manyhoods. In the Falköping programme (study 1), for programmes meant that educational, environ-example, importance was placed on raising mental and policy approaches were all feasiblepublic awareness and local journalists were and these approaches were often combined. Themembers of the multi-agency group. The owner New Zealand project aimed to cover all ages andof a local shop selling child safety products was all injury types, but in practice the focus was onalso a key member of the group. child safety. The involvement of local people and thedevelopment of local ownership were importantfeatures of several programmes, and the number Evaluationof local people participating in local programmes Of the evaluation designs employed in the 10was sometimes used as a process measure in the programmes summarized in Table 1, none have
  9. 9. Community childhood injury prevention: what works? 281used a randomized controlled design. Only one reporting, key informant interviews with coord-evaluation used several intervention and control inators and with management group members,communities (study 2), eight used one main and detailed case studies of different projectcontrol community, and one (study 8) measured components.success by a comparison of targeted and non-targeted injuries. The Statewide Child Injury Prevention Overall effectivenessProgramme in the USA (study 2) selected nine Eight of the studies were considered partiallyintervention and five control communities from effective and two inconclusive (1 and 7).351 potential cities and towns in Massachusetts,matched for a number of relevant variables. Inthe Safe Living Program (study 5), a demo- DISCUSSIONgraphically matched Shire, the Shire of Melton,was selected as a control community. In the In systematic reviews of effective injuryGreek island project, the islands of Naxos and prevention, most evaluated studies describedSpetses were selected as intervention and control relate to single countermeasures, such as thecommunities. promotion of bicycle helmets or child safety seats Two of the evaluation designs were considered (Towner et al., 2001). Community-based studies‘good’ (studies 2 and 5), two ‘good/reasonable’ such as those described in this paper, offer the(3 and 10), two ‘reasonable’ (4 and 6) and four opportunity to examine whether using a multi-‘reasonable/weak’ (1, 7, 8 and 9). agency coordinated approach provides the opportunity to change the whole culture of safety within a community and to assess the result inOutcome measures terms of health gain.Local injury surveillance systems were not only What is apparent from the results section ofused as a means of identifying local problems and this paper is the great variety in the content oftargets for interventions, but also as a source of the intervention in the 10 programmes investi-outcome data in programme evaluation. Such gated. Only in a few cases is the full extent of theoutcome data related primarily to Accident and intervention documented, e.g. the Safe LivingEmergency attendance and hospital admissions. Program, where details of the 113 programmeIn the Harstad programme (study 6), length of components have been described. One elementhospital stay was used as a proxy measure of common to nine of the 10 programmes (theinjury severity. In a few studies (5, 8, 9 and 10), exception is programme 10) is the importance ofsample population questionnaire surveys were injury surveillance systems, not just in evaluatingused to elicit self or proxy reports of injuries as the impact of the programme, but in contributingan outcome measure. Area-wide environmental to the intervention itself. Data collected in thesechanges were measured in the Shire of Bulla systems can be utilized in generating localProgram (study 5), numbers of home hazards in interest and mobilizing community involvement,the Safe Block Project (3) and the Greek Island attracting media and political interest, obtainingProgramme (9), and sales of safety equipment in resources and for targeting specific localthe Falköping study (1). Reported behaviour problems.(e.g. use of safety equipment) and knowledge For injury surveillance systems to be useful forwere used as measures of programme impact in evaluation purposes (and to make comparisonsseveral programmes. between, or to summarize findings from similar studies) it is necessary to have meaningful and consistent outcome measures. Death as an out-Process measures come is too rare an event to provide informationThe Shire of Bulla Safe Living Program, the on what to target or to be used to evaluate localLatrobe Valley Better Health Project and the campaigns. Most of the programmes have usedWaitakere Community Injury Prevention Project hospital admission or Accident and Emergency(studies 5, 8 and 10, respectively) provide more attendance as measures of non-fatal injury in adetailed documentation of the process of the community. There are flaws in using suchintervention. Process measures included pro- measures because they may reflect changes in thegramme reach, community participation, media use of, and access to, health services rather than
  10. 10. 282 E. Towner and T. Dowswelltrue injury rates. For instance, in the Latrobe of randomized controlled trials for use in com-Valley Project (study 7), changes in the hospital plex interventions has been questioned (Spellerresourcing mechanism led to large-scale variations et al., 1997) and there is considerable debate onin admission rates. One of the programmes this issue within health promotion. We agreeattempted to utilize a proxy measure of injury with this argument, but feel that the strength ofseverity, which in this case was hospital bed days. the evidence is enhanced by the selection of Injury surveillance systems are potentially appropriate control communities or comparisonexpensive to establish as part of community- groups. The provision of detail about the naturebased programmes. Several programmes relied of the intervention also enhances the interpreta-on existing (usually health care) databases for tion of results, as well as providing necessarylocal injury data. Under these circumstances, information for implementation elsewhere.data collection considerations would be likely to Evaluating the effectiveness of health promo-have a direct effect on both the selection of tion activities in the field of childhood injury isoutcomes and the selection of controls in constrained by the wide range of injury typesprogramme evaluations. If existing health infor- and variety of possible interventions. As death andmation systems are used, only a limited amount serious injury are relatively rare events, attribut-of information is collected and outcomes tend to ing health gain to a single health promotionrelate to the uptake of health services. The intervention may not be appropriate. Under theseexistence of similar data collection systems in circumstances, the collection of process data,other areas may govern the selection of control such as information on programme reach, maycommunities. This may be a very arbitrary means improve our understanding of the impact ofof choosing controls and lead to the selection of community-based approaches.control areas that appear to be very different The range of process measures employed infrom intervention communities. the different studies was diverse. Detailed case Of the 10 programmes reviewed in this paper, studies used in the Waitakere study, for example,only one has included multiple intervention and documented the importance of different modelscontrol communities: the Statewide Child Injury of programme delivery to be tailored to thePrevention Program from the USA, which needs of different cultural groups (study 10). Theselected these communities from 351 potential Maori component of the project was based in asites in the state of Massachusetts. Its inter- Marae (Maori community grouping) and allowedvention, however, only took place over a 22 month distinctive Maori perspectives of ‘a holistic viewperiod, far shorter than in many of the other of health and well-being’ to be incorporated intoprogrammes. In the other programmes only one the programme. Other process measures includedcontrol community was selected, sometimes with the degree of community involved, as reportedcomparisons with national statistics or a broader in the ‘Shire of Bulla Program’ (study 5), mediaarea. In the Harstad Programme, the intervention reporting (Falköping study), and indicators ofcommunity of Harstad with a population of a shift in the culture of safety within an organ-23 000 was compared with the city of Trondheim, ization (the local council requiring all projectsa much larger city, 1000 km away. The Safe and programmes to state how their project meetsKids/Healthy Neighborhoods Program in Harlem or furthers safety) as in the Waitakere studyhad one intervention and one control area, and (study 10).although both were disadvantaged communities,the demographic characteristics of the two areaswere different. Even when the intervention and CONCLUSIONcontrol areas were of similar size and socio-demographic mix, as in the case of the Falköping There is increasing evidence emerging regardingprogramme (study 1), there was considerable the effectiveness of community-based injuryunder-reporting in the control area, which prevention programmes. The use of multipleresulted in difficulties in interpreting the results. interventions implemented over a period of Demonstrating the effectiveness of complex time can allow injury prevention messages to beinterventions is not straightforward. Community- repeated in different forms and contexts and canbased, multi-faceted interventions that target a begin to develop a culture of safety within arange of injury types do not lend themselves to community. Important elements of community-experimental evaluation approaches. The value based programmes are a long-term strategy,
  11. 11. Community childhood injury prevention: what works? 283effective and focused leadership, multi-agency Davidson, L., Durkin, M., Kuhn, L., O’Connor, P., Barlow,collaboration, the use of local surveillance to B. and Heagarty, M. (1994) The impact of the Safe Kids/Healthy Neighborhoods Injury Prevention programdevelop locally appropriate interventions and in Harlem, 1988 through 1991. American Journal oftailoring interventions to the needs of the com- Public Health, 84, 580–586.munity. Time is also needed to coordinate existing Day, L., Ozanne-Smith, J., Cassell, E. and McGrath, A.networks, and to develop new ones. However, a (1997) Latrobe Valley Better Health Project. Evaluation of Injury Prevention Program 1992–1996, Report No.positive and sustained impact of community- 114. Monash University Accident Research Centre/based programmes on injury rates has not yet Victorian Health Promotion Foundation, Melbourne,been demonstrated conclusively. There is a need Australia.to develop valid and reliable indicators of impact Finney, J. W., Christophersen, E. R., Friman, P. C., Kalnins,and outcome appropriate to community studies. I. V., Maddux, J. E., Peterson, L. et al. (1993) Society of Pediatric Psychology Task Force report: pediatricWhere proxy measures are used for injury out- psychology and injury control. Journal of Pediatriccomes, it is important that there is clear evidence Psychology, 18, 499–526.of the association between the proxy (e.g. hazard Guyer, B., Gallagher, S., Chang, B., Azzara, C., Cupples, L.removal, knowledge gain or behaviour change) and Colton, T. (1989) Prevention of childhood injuries: evaluation of the Statewide Childhood Injury Preventionand injury risk (Towner et al., 1996). There is also Program (SCIPP). American Journal of Public Health, 79,an urgent need to develop and monitor indicators 1521–1527.to assess and monitor a culture of safety, pro- Hennessey, M., Arnold, R. and Harvey, P. (1994) The Firstgramme sustainability and long-term community Three Years: Final Report of the First Three Years of theinvolvement. Community-based injury prevention Shire of Bulla’s Safe Living Program (1991–1993). Shire of Bulla, Victoria, Australia.programmes have been hampered by the lack of Jeffs, D., Booth, D. and Calvert, D. (1993) Local injury infor-resources allocated to both their programme mation, community participation and injury reduction.development, and appropriate and rigorous Australian Journal of Public Health, 17, 365–372.evaluation. Kuhn, L., Davidson, L. L. and Durkin, M. S. (1994) Use of Poisson regression and time series analysis for detecting changes over time in rates of child injury following a prevention program. American Journal of Epidemiology,ACKNOWLEDGEMENTS 140, 943–955. Lindquist, K., Timpka, T., Schelp, L. and Ahlgren, M. (1998)This project was funded by England’s NHS The WHO safe community program for injury prevention: evaluation of the impact on injury severity.Executive National R&D Programme in ‘Mother Public Health, 112, 385–391.and Child Health’ (MCH 10-21). Manciaux, M. and Romer, C. (eds) (1991) Accidents in Childhood and Adolescence. The Role of Research. WorldAddress for correspondence: Health Organization, Geneva, Switzerland.E. Towner Moller, J. (1992) Community Based Injury Prevention. ACommunity Child Health Practical Guide. National Safety Council of Australia,University of Newcastle upon Tyne South Australia.Donald Court House Nuffield Institute for Health and NHS Centre for Reviews13 Walker Terrace and Dissemination (1996) Preventing unintentionalGateshead NE8 1EB injuries in children and young adolescents. EffectiveUK Health Care, 2, 1–16.E-mail: e.l.m.towner@ncl.ac.uk Ozanne-Smith, J., Sherrard, J., Brumen, I. and Vulcan, P. 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