The community safety approach in Falun, Sweden — is it possible to characterise the most effective prevention endeavours and how long-lasting are the results?
Introduction
Injuries are a global public health problem, causing about three and a half million deaths each year (WHO, 1993). Injury programmes at national and local levels have mainly addressed specific areas, such as traffic injuries (Haddon, 1980), falls among the elderly (Tinetti et al., 1994) and child injuries (Berfenstam, 1995). The participation of community organizations and utilization of their strategies have been suggested in order to get health promotion programmes to populations most at health risk (Rifkin, 1986), as top-down approaches have been shown to be inappropriate for reaching these groups (Gatherer et al., 1979). One way for societies to handle the increasing number of unintentional injuries has been through community-based safety promotion and injury prevention programmes covering all local injury event environments. For such a programme to be eligible for evaluation for the WHO-initiated Safe Community accreditation (Svanström, 1992) it has to maintain a cross-sectoral reference group, use existing local community networks, cover all age groups and environments, and track high-risk situations (Klang et al., 1992, Lindqvist et al., 1996).
The safe community concept has been developed in Sweden in collaboration with the World Health Organization as a framework for safety promotion and injury prevention. This framework is built upon available resources, and the prevention activities emanating from a local network of organizations and institutions. This major population strategy is based on the structure and organization specific to the community to which the model is applied (Schelp and Svanström, 1996). The potential for such a local intervention programme to reduce the injury rate in a population was first demonstrated in the Falköping municipality (Schelp, 1988, Schelp, 1989). Some years later on, similar prevention effects were reported from Norway (Ytterstad, 1995a, Ytterstad, 1995b, Ytterstad and Wasmuth, 1995). Recently, we also presented effects of a community safety approach in the municipality of Falun, Sweden (Bjerre and Sandberg, 1998). Here the programme can be interpreted to have mainly provided an active approach to injury prevention (Haddon, 1974).
Community-based injury prevention programmes have also been reported as successful in specific areas (Jansson, 1988, DeLoés, 1989, Guyer et al., 1989Bablouzian et al., 1997). In a population-oriented controlled trial intervention, strategies including multiple measures have shown a significant reduction in the risk of falling among the elderly (Tinetti et al., 1994). Also, outcome studies have been sought to complement surveys of knowledge, attitudes and behaviours for demonstrating intervention effectiveness (Nutbeam and Catford, 1987). For such studies, quasi-experimental methods have been proposed (Farquhar, 1978). In studies involving control communities, broad community-based injury prevention has been shown to reduce the total incidence of unintentional injuries requiring health care by 10–20% (Svanström et al., 1996a, Svanström et al., 1996b).
The increasing number of studies demonstrating the efficiency of local safety promotion and injury prevention programmes raises questions about how such results actually are obtained and what the principal components are. Experience has shown that there are many differences between how various community programmes are organized and that quite logically different results are to be expected (Andersson, 1995). Therefore, it would seem pertinent to make comparisons between different local intervention programmes and analyses in order to be able to transfer what has been learned to other kinds of societies and organizations. The main objective of this paper was to study some qualitative aspects while trying to characterise the most effective prevention endeavours. A comparison was made between the outcome of the preventive endeavours in relation to different injury mechanisms. Another objective of this study was to evaluate the results observed in the previous 5-year period through conducting a follow-up study and comparing the results with possible long-term historical trends. An additional valid reason for this follow-up was based on the fact that the intervention programme is still in action and a longer follow-up might create better possibilities for evaluating the lasting effects of the programme.
Section snippets
The study areas
Falun, the intervention area, is a municipality in the County of Dalarna situated in central Sweden and with a population of 55 014 (1994/95). For this study, comparisons were made with the entire County of Dalarna (population 292 103) and Sweden as a whole (population 8 817 281). Falun is a cultural centre in the Dalarna region as well as a centre of higher education. Thus, there are in fact some socio-economic and cultural differences between Falun and other parts of both the county and the
Qualitative aspects on the injury prevention programme
The community safety concept is characterized by a very broad approach towards the injury panorama in a community. This panorama is the result of an innumerable variation of injury mechanisms. The prevention endeavours focused on five different risk areas and environments through the establishment of different prevention committees. Although such a differentiation reduced the number of possible injury mechanisms in each programme area, they still remained uncountable. Nevertheless, some injury
Outcome evaluation of different injury causalities
During the first study period (September 1989–August 1995) a local surveillance system for registration of outpatients in a defined population at health centres and hospitals was put into practice. It was based upon charting all the emergency injuries attended to in the medical care system of the municipality. The injury cases were divided into five categories: home, work, traffic, sport and school. This made it possible to study the number of injuries occurring in different areas. However this
Results
The intervention programme started in 1989 and was built up gradually. Several of the prevention activities have varied both as regards their design as well as their intensity during different periods of time. An overall assessment of the entire programme showed that it was most intensive during the period 1993–1995. This period would therefore offer the best opportunity to study possible differences regarding the immediate effects of various parts of the programme.
As the injury prevention
Discussion
Injury data in this study was extracted from a national hospital discharge register. The primary aim of maintaining such a register is administrative and financial. Therefore, the interpretation of changes revealed by inpatient data is complicated by the possibility of changes in admission policies, therapeutic technologies and diagnostic-coding practices. Such changes might explain parts of the variations regarding the rates of hospital admissions, but only negligible differences between
References (37)
- et al.
Ten years of experiences from a participatory community-based injury prevention program in Motala, Sweden
Publ. Health
(1996) - et al.
The WHO safe community program for injury prevention: evaluation of the impact on injury severity
Public Health
(1998) The role of organizations in community participation — prevention of accidental injuries in a rural Swedish municipality
Soc. Sci. Med.
(1988)- et al.
Preventing femoral fractures among elderly — the community safety approach
Safety Sci.
(1996) - et al.
The Harstad injury prevention study: evaluation of hospital-based injury recording and community-based intervention for traffic injury prevention
Accid. Anal. Prev.
(1995) Community safety at local, regional and national levels
Int. J. Consumer Safety
(1995)- et al.
Evaluation of a community-based childhood injury prevention program
Injury Prev.
(1997) Sweden’s pioneering child accident programme: 40 years later
Injury Prev.
(1995)- et al.
Sweden’s experience in reducing childhood injuries
Pediatrics
(1991) - et al.
The community safety approach in Falun, Sweden — What makes it work?
Int. J. Consumer Safety
(1998)
The effects of a community-based injury prevention study in Falun, Sweden — Outpatient and hospital-based injury records
Int. J. Consumer Safety
Organization for a community cardiovascular health program
Health Ed. Q.
The community based model of life style intervention trials
Am. J. Epidemiol.
Prevention of childhood injuries: evaluation of the statewide childhood injury prevention program (SCIPP)
Am. J. Public Health
Strategy in preventive medicine: passive vs. active approaches to reducing human wastage
J. Trauma
Cited by (26)
Intentions and knowledge shaping local safety policy: A comparison of two Swedish cities
2015, Journal of Safety ResearchCitation Excerpt :The notion of LSP reflects a broad and dynamic understanding of policy as it evolves in the policy process. In the safety science literature, other terms are used to refer to safety interventions and work covered by the concept (e.g., injury preventions programs covering all local injury event environments; Bjerre & Schelp, 2000; see also Nilsen, 2007). Intentions and knowledge guide and drive policies and programs (Schneider & Ingram, 1997; Jones, Boushey, & Workman, 2006; Wagenaar, 2007).
Intentions and knowledge constructing local safety policies: A framework of analysis
2015, Safety ScienceCitation Excerpt :The notion of LSP reflects a broad and dynamic understanding of policy as it evolves in the policy process. In the safety science literature, other terms are used to refer to safety interventions and work covered by the concept e.g. ‘injury preventions programs covering all local injury event environments’ (Bjerre and Schelp, 2000; see also Maurice et al., 2001; Nilsen, 2007; Klassen et al., 2000). One way to improve local safety policies and programs is to increase the use of knowledge from research and evaluation.
Tools for empowerment in local risk management
2008, Safety Science