• community

In this issue, Istre and colleagues report results from an intervention to increase child restraint use in a multi-ethnic Dallas neighbourhood (see page 3).1 This was an impressive undertaking, couched in the theory and principles of community-based prevention interventions. Investigators conducted formative work with community stakeholders, some of which is detailed in a linked, online white paper. Modifications to intervention design based on these qualitative assessments included a focus on schools as points of neighbourhood cohesion and the use of car seats ‘blessed’ by local religious organisations.

The intervention was studied using a quasi-experimental design not uncommon in community-based efforts. As suggested by Langley et al, the outcomes of interest were not relatively rare injury occurrences, but rather the observed prevalence of important injury-risk reduction behaviours.2 Results were based on almost 10 000 individual child restraint use observations. Analysis accounted for the clustered, multi-levelled nature of the intervention and data collection activities.3

The results are presented as an example of ‘the Safe Communities model approach to injury prevention.’ The Safe Communities movement is a worldwide effort through which several hundred cities or municipalities have been (or are working to become) certified as safe communities.4 In general, this requires communities to collect local injury data, use these data to engage broad cross-sections of society in the planning and execution of prevention programmes or policies, and evaluate the results of their interventions.5 Although based on principles that most would consider sound, the Safe Communities model struggles with the same challenges that other community-based health promotion schemes have faced—it is difficult to show that they actually work.6 7

The question arises, then, as to whether Istre's work in Dallas adds to the evidence in support of the Safe Communities approach. Certainly, the paper shows a positive result in a relatively well designed and executed study. The authors are careful to show that their work followed the prescribed ‘model’ promoted by Safe Communities for prevention interventions: essentially an injury-focused, community-based health promotion approach. But these are features of the specific programme, which are not necessarily attributable to its location in a designated Safe Community. One has to ask, to what extent was the success attributable to the Safe Community status that Dallas has enjoyed since 1996?

The intervention in Dallas (like many interventions designed in compliance with the Safe Communities model) was a well crafted, multi-pronged programme that used community input to identify strategies and locations to best engage a target population. Classes, seat checks, and awareness campaigns were designed to change individual behaviours. But what happened at the community level? Were policies or programmes created to promote restraint use across the community? Was there an effort to change behavioural norms and expectations? Was there, at least, evidence that programmes were easier to implement or more successfully conducted because of infrastructure attributable to the Safe Community? If not, then what exactly does the Safe Communities designation achieve in terms of individual safety?

One would like to believe (it seems to me) that a Safe Community would somehow value and promote safety in a manner that enhances, or at least facilitates, injury prevention interventions. More specifically, one should be able to identify and measure the contextual interventions and impacts that sit as the foundation of community-based prevention activities.8 Broadly considered, it also seems that ‘safety promotion’ should reach beyond injury control to engender a sense of safety that might manifest as engagement in activities, less anxiety about injury risk, and a greater perception of health, well being, and community investment.

But these outcomes are rarely measured. The benefits of the Safe Community are boiled back down to a reduction of risk behaviours or injury occurrence. In fact, this may be a simple necessity. For all the intangible warmth of safety promotion as a concept, the tools we have to achieve this are very often targeted, discrete injury prevention interventions. And to be fair, many injury prevention strategies do reach ‘upstream’ in the causal chain and broadly out into the relevant environments to effect their change. In so doing, they must—to some extent—promote a safer community.

It remains plausible that there is another, largely untapped—or, at least, understudied—aspect of the Safe Community to consider. This is the opportunity to move entire communities, not just identified subpopulations, towards safer behaviours, practices, and policies. Why target communities? First, because some aspects of risk are mediated by conditions and influences quite distinct from individual behavioural decisions. Decisions made at a community level about zoning, traffic control, and recreational facilities influence injury risk in ecological domains that individuals simply cannot manipulate. Perhaps more importantly, even small reductions in risk applied over entire populations can have a dramatic impact on the total burden of disease or disability. The health of a population can improve through a gentle nudge in a positive direction, if this is taken up by a malleable majority. Impacts on health equity notwithstanding, the results of such intervention could dwarf those achievable through engagement only with targeted ‘high risk’ individuals.9

This, at least, is the theory. Only a few investigators have carefully specified an ecologically based theory of injury causation, defined measures to operationalise the concept, and tested prevention interventions against that theory (see Pickett et al,10 for example). We need more studies to explicitly test community-focused injury prevention programmes, looking for an interaction between Safe Communities designation and the success, reach, and sustainability of these programmes. Where there are successes, we need to know how these were achieved. Was community participation an important component? What about policies and legislation? Was inter-sectoral collaboration involved? Was an ‘all injury’ approach taken or were injury issues isolated, segmented, and targeted? Finally, can we see a spillover effect? Does success in one area of injury prevention lead to successes in other injury or non-injury health domains? And if we are to believe, as I do, that safety is more than an absence of injury, we need to be able to describe and measure this concept as the ultimate and most appropriate outcome of a Safe Community initiative.