Leading ArticleEvaluation of an inter-organizational prevention program against injuries among the elderly in a WHO Safe Community
Introduction
Unintentional injuries are a major health problem among elderly people.1, 2, 3, 4 Falls, traffic accidents and burns are common causes of fatal injuries in this age group.5 Of these categories, falls are the leading cause of deaths from injury among people aged over 75.6 Fall injuries, mainly fractures, are also a common and costly cause of hospital admission. The fall injury aetiology is complex, including osteoporosis as a significant factor.7 There is a large number of epidemiological studies which in detail have outlined the risk factors for falls.5, 8, 9, 10 Fewer studies consider the total picture of injuries among the elderly. Although injury prevention can be undertaken at all levels, the community-based model, adapting interventions to the local cultural, social and organizational environment and emphasizing broad community participation, has emerged as one of the most promising models.11, 12 Focused community-based programs have also been reported as successful in reducing the risk of falling among elderly people.13, 14, 15, 16
In Sweden, the age group of 65 and older constitutes 16% of the population but contributes more than half of all deaths due to injuries. When hospital discharge data are studied, falls in the home environment are the dominant injury events among the elderly population.17, 18 For prevention of unintentional injuries, community intervention models have been developed in this country based on popular participation and inter-sectoral co-operation between authorities, scientific institutions, and local practitioners. Guided by participatory research methods,19 these models propose co-operation between local politicians, civil servants, representatives of non-governmental organizational and public health workers.20 The first community development program aiming at preventing injuries was initiated in 1978 in the municipality of Falköping.21 Here, the potential to reduce the injury rate in a general population was also demonstrated.22
In contrast to focusing only on falls, the objective of the present study is to evaluate the WHO Safe Community model with regard to all unintentional injuries among the elderly. So far few studies on the outreach of participatory community-based injury prevention among the elderly have been published. The WHO Safe Community concept was launched on a Swedish initiative in 1989 and provides a model for safety promotion and injury prevention work in the local community. In particular, the aim is to study morbidity rates in injuries treated in health care before and after the program implementation using a quasiexperimental design. An assessment of the program structure and process has previously been reported.23
Underpinning the Safe Community model is the principle that all preventive actions should rely on local community motives and resources. Hereby tensions between societal rationality and local democracy are to be balanced. A functionalist perspective of the social system is used,24 where consensus and gradual adjustments are emphasized in favor of pointing at conflicts and suggesting radical changes. All three of Rothman's25 proposed strategies for participative community interventions are included:
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organization of a local cross-sectoral action group (for local ownership);
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reliance on existing local community networks (for planning); and
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continuous tracking of high-risk environments and groups (for targeted social action).
The evaluated Safe Community program was implemented in Motala municipality in the western part of Östergötland County in Sweden. The theoretical framework was used in a step-by-step participative strategy for community involvement. Regarding injuries among the elderly, the aim of the community analysis stage of the program,26 performed in 1983–1984, was to study the local epidemiology of injuries among the elderly, to follow the economic consequences of these injuries, and to analyse the local social structure and values.27, 28, 29 The morbidity rate for unintentional injuries among the elderly was found to be 77 per 1000 population years. The most common injury event contexts were at home (63%) and in the traffic environment (18%). Seventy per cent of the injuries were caused by a fall, and two out of three of these occurred on an even surface. The upper and lower extremities were the most common anatomical locations, accounting for one third of the injuries each. Stage two, the program design and initiation (1985–1987) included organizing the management of the intervention and setting local planning goals. The district Health Services Board, the Municipal Board, and political committees and management groups were approached to accept responsibility for acting on the results of the community analysis. The goal set for the program was to reduce the total injury incidence in the municipality by 25% by the year 2000. The design evolved into an action program during the implementation stage (1987–1988). Safety among the elderly was pursued through a self-regulatory local Safety Council for the Elderly with representatives of the municipality administration, the county council, pensioners' organizations, sporting organizations and the Red Cross. The practical prevention work was carried out in co-operation with the municipality's social workers and district nurses, and in association with non-profit organizations which support the elderly.
During the implementation years, the Safety Council for the Elderly used their influence on the local social network to eliminate general safety hazards. Examples include improvements in winter road maintenance, reconstruction of pavements and walkways adjacent to social service institutions and improvements in evening-time illumination in public places and walkways. Behavioral safety education and information programs were also supported. Regarding information at the community level, regular features on injury prevention were provided in the local mass media. Displays of various safety products were maintained in public places on a regular basis. At the individual level, safety information was combined with assistance to adjust the home environment and support daily physical exercise. All elderly who received assistance in their homes were provided with specific information and education measures, such as a pamphlet with advice and an injury prevention check list. Individuals estimated to be at high risk were addressed through the social service aides supporting the elderly. Besides revising the home environment, a ‘Safe Daily Walk’ program was carried out where the aides joined the elderly on regular exercise walks. Finally, at all homes for the elderly in the area, the staff members were provided with a specific course in injury prevention. At stage four, program maintenance-consolidation (1989–1995), the facilitator withdrew from the Safety Council for the Elderly, and intervention activities were completely integrated into existing community networks. The final stage, evaluation (1995–1999), focused on assessing and reporting from the program.
Section snippets
Materials and methods
A quasi-experimental design30 was used with pre- and post-implementation registrations covering the total populations in the program implementation area and in a neighboring control municipality in Östergötland county. Change in the morbidity rates following the intervention was studied using prospective registration of all acute care episodes during the study period. Since the study areas were not randomly chosen, environmental indicators were studied. To avoid bias, the research team was
Environmental indicators
At the start of the study, the age and sex mix in both areas was close to the national average. Between the registration periods, the number of elderly in the community increased by 8% both in the study and control areas. Residential and income characteristics remained stable (Table 1). The general educational level in both areas was slightly below the national average and showed a tendency to increase (Table 2).
Quality of registrations
During the pre-implementation registration period, which included all ages of the
Discussion
The objective of this study was to assess the WHO Safe Community model concerning morbidity in unintentional injuries among the elderly. The model has its cornerstones in participative community interventions based on local cross-sectoral action groups, reliance on existing local community networks, and continuous tracking of high-risk environments and groups. The most important finding was that whereas the total injury morbidity decreased marginally, there was a clear reduction of non-minor
Acknowledgements
This study was supported by grants from the Swedish National Institute of Public Health, and the Östergötland County Council.
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