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There has long been interest within the injury prevention community regarding perceptions and framing of our work.1–3 Studies have examined how health professionals1 and the public2 interpret the meaning and preventability of an accident. A recent study by Smith and colleagues was the first to examine US news media inclusion of a modifier to the term accident.3 Their exploratory study reviewed the use of freak accident in coverage of injury events. This ongoing professional dialogue regarding the term accident and its implications for injury prevention has led to broad exclusion of the term from communication within our field (despite the lack of conclusive evidence to support such removal). For example, BMJ banned the term in 2001.4 We suggest that there is an additional term that requires similar dialogue.
In June 2010, the Drexel University School of Public Health was awarded a 3-year Assistance to Firefighters Grant from Federal Emergency Management Agency and the Department of Homeland Security. The goal of the project is to develop and test the architecture for a non-fatal injury surveillance system for the US fire service. The original name of the project reflected that goal: ‘Firefighter Non-fatal Injury Surveillance System’ or F-NISS for short. Since the project is strongly influenced by the needs and guidance of the fire service and the safety research community, an expert advisory board representing both groups was appointed at the project's inception. The board's prominent role ensured the incorporation of key principles that we know guide successful partnerships between community members and research or academic groups. These principles include active community involvement and the building of mutual trust and respect.5 The incorporation of these principles is essential to understanding a target population when beginning formative research for surveillance, health communication campaigns or intervention development.
Therefore, we took note when early discussions with board members highlighted what a few other injury prevention colleagues have noted6: that surveillance has a different meaning, with a negative connotation, to those outside of public health. To further explore this issue, we conducted two conference calls with five advisory board members who hold leadership positions within the US fire service. The goal of the calls was to explore their perceptions of the term and the potential impact of its usage on community buy-in for the project.
Most participants revealed that the term has negative connotations that could make firefighters feel that they are being watched or potentially punished for being injured. For example, one participant stated:
…the term surveillance is extremely negative. It's guys with guns, and cops, and cameras and reporting.
Another participant shared a similar sentiment incorporating past experience with the term:
I do know that our normal thinking of surveillance and injuries is the whole workers’ comp scam, where firefighters have repeatedly been video-surveilled chopping wood and lifting cars and stuff like that when they're off-duty from a back injury. And I think that would be what would drive the negative piece of this. That's how surveillance has been used before. In other words, it's been used to hurt the firefighters, from their perspective…
As a result of the conference calls, the research team decided to remove the term surveillance from the project name and website (http://publichealth.drexel.edu/first/). The revised project name, Firefighter Injury Research and Safety Trends was constructed using terms like safety, which received positive feedback from call participants. While removing the term from the project is one strategy for reducing barriers between public health and community partners, it is not the only option. Several observations emerged from our experience.
First, data collection projects could be used as an opportunity to educate community partners about public health surveillance and highlight the characteristics that differentiate it from other types of surveillance. There is some evidence in the literature to show that there have been previous efforts to highlight this distinction. For example, Thacker and Berkelman write that epidemiologic was first used as a modifier to the term surveillance in the mid-1960s.7 They state that one purpose of the modifier was to ‘distinguish this activity from other forms of surveillance, such as military intelligence’. While this distinction was made in the literature, it is unclear how or if it is highlighted in practice. What is known is that coalition building around an injury surveillance system is essential to its success.8 These efforts should be subsumed with a larger initiative to educate community partners about relevant public health topics, including the purpose of surveillance and its role in prevention. Thus surveillance becomes normalised in the community lexicon.
Second, public perceptions of the term surveillance (and its various modifiers) should be systematically and formally researched. The calls described here were conducted with a small convenience sample of high ranking fire service officers on the Firefighter Injury Research and Safety Trends advisory board. While the researchers who led the calls followed a predetermined script of questions, the format and facilitation was less structured than what would be required in formal focus groups or interviews. Due to such limitations, we are not able to determine if these concerns are representative of the entire US fire service or if they are shared by other occupational or demographic groups. We need research and dialogue within the field before any recommendations can be made regarding effective modifiers or the possible development of a new technical term to replace surveillance.
Finally, we acknowledge that the issue of whether surveillance presents a communication barrier will depend on the group with which you are working. For example, we anticipate that there may be concerns about surveillance expressed by certain populations (eg, those mistrustful of the police) or regarding particular health behaviours (eg, those that are illegal). The testing and selection of appropriate language is essential as these terms are used to engage stakeholders, assess needs, communicate risk and disseminate results. Therefore, we recommend that the development of an injury surveillance project begin with an assessment of the target population's response to the term. The absence of this crucial step could greatly inhibit stakeholder buy-in and ultimately the project's success. Steps should also be taken to catch any oversight in this regard during the project's formative or process evaluation. Project leaders would then have the opportunity to address concerns, educate the community and tailor communication before the precious resources of community engagement and funding would be spent.
Surveillance is essential to designing, implementing and evaluating injury prevention efforts around the world.9 The resulting data are vital for public health education, research, policy development, and programme implementation and evaluation. However, without sufficient understanding by the public, we run the risk of injury surveillance continuing to be misunderstood, underfunded, and not robust enough to yield the needed results. The US Centers for Disease Control identified a number of challenges when communicating about injury with the public10 and called for the usage of coordinated messages to address these challenges. Their published analysis did not include a discussion of the term surveillance. We urge our colleagues in injury research and practice to further consider how we communicate about this vital component of injury prevention. We encourage discussion from the global community as to whether or not different cultural perceptions of the term surveillance exist and how this might impact communication.
Footnotes
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Contributors All authors contributed to this manuscript in the following ways: Conception and design, drafting the article and revising it critically for important intellectual content, final approval of the version published.
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Funding Research for this article was supported by the Federal Emergency Management Agency (FEMA) FY 2009 Assistance to Firefighters Grant Program, Fire Prevention and Safety Grants (Research & Development). Grant No. EMW-2009-FP-00427.
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.