Elsevier

Safety Science

Volume 43, Issue 10, December 2005, Pages 815-833
Safety Science

Towards improved understanding of injury prevention program sustainability

https://doi.org/10.1016/j.ssci.2005.08.015Get rights and content

Abstract

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.

Introduction

Sustainability of programs and interventions is generally desirable in public health, including in the area of injury prevention. Community-based programs to promote health and prevent disease and injuries are long-term by nature and take more time to develop and implement than less comprehensive interventions (Elder et al., 1993). Engaging community members and developing community collaborations typically require a substantial commitment of time and energy (Brownson et al., 1999, Merzel and D’Afflitti, 2003). Hence, premature termination of effective community-based injury prevention programs can prevent the attainment of safety goals; long-term program viability is often a prerequisite for meaningfully assessing outcomes. Insufficient intervention duration is a factor that explains the lack of significant effectiveness of many injury prevention programs (Nilsen, 2004). Prior to the 1990s, the literature on health promotion and injury prevention did not give much consideration to the problems of maintaining programs over longer periods of time (Goodman and Steckler, 1989, Bracht, 1990, Lefebvre, 1992). However, attention to the sustainability of health intervention programs has increased in recent years, as policy makers and funders have become more concerned with allocating scarce resources effectively (Shediac-Rizkallah and Bone, 1998).

The importance of long-term program maintenance is recognised in the World Health Organisation (WHO) Safe Community model for community-based injury prevention; one of the six Safe Community program accreditation criteria states that the programs must be “long-term and sustainable” efforts (WHO Collaborating Centre, 2005). Regrettably, no information is provided regarding how to achieve this or what may constitute a “long-term and sustainable” program. Still, this lack of guidance is perhaps not surprising considering the lack of consensus about conceptual and operational definitions of sustainability of health programs (Pluye et al., 2004). Moreover, an empirical knowledge base about factors facilitating and working against sustainability is still at an early stage (Crisp and Swerissen, 2002, Barnett et al., 2004). Indeed, although hundreds of community-based injury prevention programs have been implemented since the mid-1970s, only a handful of studies have documented sustainability of programs and effects (O’Loughlin et al., 1998).

Although health program planners are usually concerned with program effectiveness, often there is little direct planning for long-term sustainability of health and safety programs in the community. There is a need for a greater emphasis on understanding processes that lead to sustainable programs (Shediac-Rizkallah and Bone, 1998, Crisp and Swerissen, 2002). To date, research on health program sustainability has focused on “institutionalisation”, i.e., how programs can survive the transition from dependence on outside support to continuance supported by local resources (e.g., Steckler and Goodman, 1989, Bracht et al., 1994, Rissel et al., 1995), and how programs can survive the transition of the program delivery from an experimental context controlled by researchers to control by community organisations (e.g., Altman, 1995).

The purpose of this study is to explore factors that contribute to or detract from the sustainability of community-based injury prevention programs. The factors were derived from interviews with key informants from 10 Swedish WHO Safe Communities. There is no known study that specifically investigates the sustainability of community-based injury prevention programs or the sustainability of programs that are incorporated into the normal function of a local government, as is the case with Swedish Safe Communities. The aim of this study is to contribute to improved understanding of the conditions under which injury prevention programs are most likely to attain sustainability.

Section snippets

The concept of sustainability

Due to a lack of agreement as to what is meant by sustainability, it is important to clearly define this concept in relation to injury prevention programs. Sustainability has been defined as the maintenance of a program at a level of activity that will provide continuing management of a health problem (Claquin, 1989) or program delivery of intended benefits over a long period of time (The World Bank’s definition, in Bamberger and Cheema, 1990). Thus, sustainability may refer both to health

Financial resources

There was consensus among the program coordinators that available financial resources ultimately determine the ambition level of the program by imposing a limit on the personnel resources and time that can be devoted to the injury prevention work. The programs rely to a very high degree on voluntary work, often with the program coordinator being the sole person fully employed to work with injury prevention issues. Some of the municipalities of this study faced economic adversity, which directly

Discussion

This study sought to uncover factors that influence the sustainability of community based injury prevention program, using study data from 10 Swedish long-term programs, designated WHO Safe Communities, which are incorporated into the routine functions of local governments. The programs were analysed with respect to how seven study elements affect program sustainability: financial resources, human resources, relational resources, structural resources, activities, effects, and context.

The

Conclusions

The results of this study suggest that different factors are interrelated, with no one factor being either primary or by itself sufficient for program sustainability. Financial resources, “translated” into personnel resources and time devoted to the program, determine the overall ambition level of the program. The programs are integrated within existing municipality structures, which make them vulnerable to changes in the financial status of the municipality and the priority-setting by the

Acknowledgements

This study was supported by grants from the Swedish National Rescue Services Board. Sincere thanks to Michael Bourne, Felicia Gabrielsson, Agneta Kullberg, Lena Strindlund, and Pia Ödman for comments on earlier drafts of his paper.

References (64)

  • A. Benson

    The evaluation of community-based injury prevention activity: the UK perspective

    Injury Prevention

    (1995)
  • B. Bjerre et al.

    The community safety approach in Falun, Sweden. What makes it work?

    International Journal for Consumer and Product Safety

    (1998)
  • G. Bjärås

    The need of leadership for motivation of participants in a community intervention programme

    Scandinavian Journal of Social Medicine

    (1991)
  • G. Bjärås et al.

    A new approach to community participation

    Health Promotion International

    (1991)
  • A. Bounfour

    The Management of Intangibles

    (2003)
  • Bourne, M., Nilsen, P., Hudson, D., submitted for publication. Towards safer communities?—an examination of the...
  • A. Bowling

    Research Methods in Health

    (2002)
  • N. Bracht et al.

    Community ownership and program continuation following a health demonstration project

    Health Education Research

    (1994)
  • N. Bracht

    Introduction

  • N. Bracht et al.

    Community organization principles in health promotion: a five-stage model

  • R.C. Brownson et al.

    Challenges in community-based prevention

  • CART Team

    Developing methodologies for evaluating community-wide health promotion

    Health Promotion International

    (1996)
  • P. Claquin

    Sustainability of EPI: Utopia or Sine Qua Non Condition of Child Survival

    (1989)
  • B. Crisp et al.

    Program, agency and effect sustainability in health promotion

    Health Promotion Journal of Australia

    (2002)
  • L. Doll et al.

    Evaluation of interventions designed to prevent and control injuries

    Epidemiologic Reviews

    (2003)
  • R. Ekman et al.

    Evaluation of safety interventions—difficulties and possible solutions

  • J.P. Elder et al.

    Community heart health programs: components, rationale, and strategies for effective interventions

    Journal of Public Health Policy

    (1993)
  • L. Ewles et al.

    Community health development on a Bristol housing estate: a review of a local project ten years on

    Health Education Journal

    (2001)
  • J.R. Feagin et al.

    A Case for the Case Study

    (1991)
  • N.S. Fielding et al.

    Linking Data

    (1986)
  • B.S. Flynn

    Measuring community leaders’ perceived ownership of health education programs: initial tests of reliability and validity

    Health Education Research

    (1995)
  • R.M. Goodman et al.

    A model for the institutionalization of health promotion programs

    Family and Community Health

    (1989)
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