Towards improved understanding of injury prevention program sustainability
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.
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