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Opening the Black Box of Community-Based Injury Prevention Programmes: Towards Improved Understanding of Factors that Influence Programme Effectiveness
Linköping University, Department of Medicine and Health Sciences, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences.
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Despite wide application of community-based programmes to prevent injuries and promote health over the last 25 years, there is a paucity of evaluations from which to obtain evidence regarding the effectiveness and critical factors contributing to achieving effectiveness of these programmes. Research on community-based injury prevention programmes thus far has been driven by the question “does it work?” However, merely establishing whether a programme works or not provides insufficient information to generate new knowledge about these programmes. Many programme evaluations have been characterised as “black box” evaluations, with inadequate information about the intervening and contextual factors that mediate the relationship between the programme and its effects. Opening the black box is essential to developing the best evidence in relation to community-based programmes.

Keeping the question “does it work?” in mind as a departure point, the seven studies of this thesis address different aspects of the questions “why does it work?” and “how does it work?” The aim is to aid in the understanding of factors that influence the operation and effectiveness of community-based injury prevention programmes.

The findings from the studies support a number of conclusions with regard to the three research questions posed. There is limited evidence for the effectiveness of communitybased injury prevention programmes. Some of the problems of providing convincing evidence are due to the methodological difficulties of evaluating these programs.

Contextual conditions and the amount of financial resources available to a programme are key factors associated with the effectiveness of community-based injury prevention programmes. There is inconclusive evidence regarding the importance of some of the socalled success factors described in the scientific literature for achieving effectiveness. While many programmes have access to locally collected injury data, they devote limited time to the analysis of this ssembled data. When selecting interventions, many programmes rely upon tuitive and subjective methods, e.g. discussions in networks, feedback from the general public, and experiences gained in their own work. This style of decision making is “experience-based” rather than evidence-based.

The theoretical underpinning of the community-based approach has certain shortcomings, which could explain some of the difficulties in demonstrating effectiveness seen with many of these programmes. Programmes overwhelmingly define geographical units as communities. However, these entities can be highly heterogeneous and characterised by a weak sense of community, which can yield insufficient community member participation and intersectoral collaboration, as well as inadequate reach for many programmes. At the same time, none of the most plausible assumptions of the community-based approach appears to be fully or widely applied in programme practice. The implication is that many community-based programmes do not function at an optimum level.

Place, publisher, year, edition, pages
Institutionen för hälsa och samhälle , 2006.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 948
Keyword [en]
Community-based, injury prevention, programmes, evaluation, effectiveness
Keyword [sv]
Samhällsbaserad, skadeprevention, program, utvärdering, effektivitet
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-7001ISBN: 91-85497-85-1 (print)OAI: oai:DiVA.org:liu-7001DiVA: diva2:22091
Public defence
2006-06-07, Aulan, Hälsans hus, Hälsouniversitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2006-06-26 Created: 2006-06-26 Last updated: 2013-09-05
List of papers
1. What makes community based injury prevention work?: In search of evidence of effectiveness
Open this publication in new window or tab >>What makes community based injury prevention work?: In search of evidence of effectiveness
2004 (English)In: Injury Prevention, ISSN 1353-8047, Vol. 10, no 5, 268-274 p.Article in journal (Refereed) Published
Abstract [en]

Community based injury prevention work has become a widely accepted strategy among safety promotion specialists. Hundreds of community based injury prevention programs have been implemented since the mid-1970s, but relatively few have been evaluated rigorously, resulting in a lack of consensus regarding the effectiveness of this approach. This study sought to identify key components that contribute to the effectiveness of these programs. The objective was to gain a better understanding of the community based model for injury prevention. The study was performed as a structured review of existing evaluations of injury prevention programs that employed multiple strategies to target different age groups, environments, and situations.

The results of this study suggested that there are complex relationships between the outcome and the context, structure, and process of community-wide injury prevention programs. The interconnectedness of these variables made it difficult to provide solid evidence to prioritise in terms of program effectiveness. The evaluations of multifaceted community oriented injury prevention programs were found to have many shortcomings. Meagre descriptions of community characteristics and conditions, insufficient assessment of structural program components, and failure to establish process-outcome relationships contributed to the difficulty of identifying key success factors of the programs.

Keyword
community based injury prevention, evidence of effectiveness
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13873 (URN)10.1136/ip.2004.005744 (DOI)
Available from: 2006-06-26 Created: 2006-06-26 Last updated: 2009-05-28
2. Effectiveness of Community-Based Injury Prevention: Injury Rate Levels, Changes, and Trends for 14 Swedish WHO-Designated Safe Communities
Open this publication in new window or tab >>Effectiveness of Community-Based Injury Prevention: Injury Rate Levels, Changes, and Trends for 14 Swedish WHO-Designated Safe Communities
Show others...
2007 (English)In: Accident Analysis and Prevention, ISSN 0001-4575, Vol. 39, no 2, 267-273 p.Article in journal (Refereed) Published
Abstract [en]

This study investigates the injury rate levels, changes, and trends between 1987 and 2002 for the 14 Swedish municipalities designated as WHO Safe Communities. The injury rate was defined as the number of injured patients discharged from hospital per 1000 persons. Injury rates were age standardised. Each municipality was compared with its respective municipality group, according to a classification of Sweden's 288 municipalities into nine groups based on numerous structural parameters.

The average injury rate levels for the 14 WHO-designated Safe Community municipalities ranged from 11.54 to 19.09 per 1000 population during the study period, which was defined as the time period during which a municipality's injury prevention program has been operational. Eleven of 14 municipalities had higher levels than their corresponding municipality groups. Five of the 14 municipalities “outperformed” their respective municipality groups and achieved a greater relative injury rate decrease during the study period. The trends for the 14 municipalities in relation to their municipality groups showed an inconsistent pattern, with only four municipalities exhibiting overall favourable trends for the study period.

Keyword
Intervention effectiveness, Community-based, Injury prevention, WHO Safe Community
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13874 (URN)10.1016/j.aap.2006.07.007 (DOI)
Available from: 2006-06-26 Created: 2006-06-26 Last updated: 2009-05-08
3. Towards improved understanding of injury prevention program sustainability
Open this publication in new window or tab >>Towards improved understanding of injury prevention program sustainability
2005 (English)In: Safety Science, ISSN 0925-7535, Vol. 43, no 10, 815-833 p.Article in journal (Refereed) Published
Abstract [en]

As policy makers and funders have become more concerned with allocating scarce resources effectively, attention to the sustainability of health intervention programs has increased. However, the empirical knowledge base about factors facilitating or working against sustainability remains at an early stage. The aim of this study was to contribute to improved understanding of the conditions under which community-based injury prevention programs are most likely to attain sustainability. Ten Swedish community-based injury prevention programs were analysed with respect to factors that contribute to or detract from program sustainability. All the programs are integrated within existing municipality structures. Data were collected by means of semi-structured telephone interviews with key informants.

The results suggested that different factors are interrelated, with no one factor being either primary or by itself sufficient for program sustainability. Financial, human, and relational resources lay the groundwork for the long-term operation of a program. The “integrated” program model appears to facilitate sustainability, but program intensity is vulnerable to changes in the financial status of the municipality and the priority-setting by municipality political decision makers. Sustainability may be compromised if a program becomes too dependent on a few key individuals. In contrast to financial, human, and relational resources, structural resources (e.g., injury surveillance and goals) appeared to have limited influence on sustainability. The programs were sustained with little evidence of effectiveness, resulting in limited feedback about how to improve a program in order to achieve and maintain long-term effectiveness.

Keyword
Sustainability; Resources; Activities; Effects; Context
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13875 (URN)10.1016/j.ssci.2005.08.015 (DOI)
Available from: 2006-06-26 Created: 2006-06-26 Last updated: 2013-09-05
4. Strategies and goals of community-based injury prevention programmes: a mixed-methods study of 25 Scandinavian WHO Safe Communities
Open this publication in new window or tab >>Strategies and goals of community-based injury prevention programmes: a mixed-methods study of 25 Scandinavian WHO Safe Communities
2006 (English)In: International Journal of Injury Control and Safety Promotion, ISSN 1745-7300, Vol. 13, no 1, 27-33 p.Article in journal (Refereed) Published
Abstract [en]

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.

Keyword
Strategies; Measures; Goals; Objectives
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13876 (URN)10.1080/15660970500077352 (DOI)
Available from: 2006-06-26 Created: 2006-06-26
5. Using Local Injury Surveillance for Community-Based Injury Prevention: an Analysis of Scandinavian WHO Safe Community and Canadian Safe Community Foundation Programs
Open this publication in new window or tab >>Using Local Injury Surveillance for Community-Based Injury Prevention: an Analysis of Scandinavian WHO Safe Community and Canadian Safe Community Foundation Programs
2007 (English)In: International Journal of Injury Control and Safety Promotion, ISSN 1745-7300, Vol. 14, no 1, 35-43 p.Article in journal (Refereed) Published
Abstract [en]

Injury surveillance is widely recognized as a critical prerequisite for effective injury prevention, yet few studies have investigated its use by community-based injury prevention programmes. This study examined the extent to which local injury data were collected, documented, analysed, linked to injury prevention action and used for evaluation among WHO Safe Communities in Scandinavia (25 programmes) and the Canadian Safe Community Foundation (SCF) network (16 programmes). For each programme, a key informant with relevant local knowledge was selected to respond to an emailed questionnaire. The study demonstrates that community-based injury prevention programmes experience difficulties accessing and effectively utilizing local injury surveillance data. The findings suggest that the responding SCF programmes approach injury prevention more scientifically than the Scandinavian WHO-designated Safe Community programmes, by making greater use of injury surveillance for assessment, integration into prevention strategies and measures, and evaluation. Despite study limitations, such as the low response rate among Canadian programmes and a large number of non-responses to two questions, the results highlight the importance of, and need for, greater use of local injury surveillance.

Keyword
wounds & injuries, prevention, community organization, questionnaires, response rates, Scandinavia, Canada, community-based injury surveillance
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13877 (URN)10.1080/17457300600864447 (DOI)
Available from: 2006-06-26 Created: 2006-06-26 Last updated: 2009-05-08

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