Health Promotion International, Vol. 18, No. 3, 237-245,
September 2003
© Oxford University Press 2003
The process and impact of implementing injury prevention projects in smaller communities in New Zealand
Injury Prevention Research Unit, University of Otago, New Zealand and 1Environment Management and Design Division, Lincoln University, New Zealand
Address for correspondence: Jean Simpson, Injury Prevention Research Unit, University of Otago, PO Box 913, Dunedin, New Zealand, E-mail: jean.simpson{at}ipru.otago.ac.nz
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SUMMARY |
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It has been argued that developing community projects is an effective means by which to reduce injury. Two pilot community injury prevention projects (CIPPs) were established in small communities in New Zealand based on the World Health Organization (WHO) Safe Community model. The process and impact of the implementation of these CIPPs was monitored over 3 years. The setting was two small New Zealand communities with populations of <10 000. An external process and impact evaluation was conducted, with data gathered from written documentation, informant interviews and observation. The WHO Safe Community criteria formed the basis of the evaluation framework used. Other essential factors included were identified through the literature and the projects themselves. Findings from each CIPP were considered independently, followed by an examination of the differences observed. The findings from the evaluation of the implementation of these CIPPs are reported in relation to the themes identified in the evaluation framework, namely: community context, ownership and participation, focus and planning, data collection, leadership, management, sustainability and external links. Despite the different contexts, a common conclusion was that if the CIPPs’ success was dependent on achieving a meaningful reduction of injury, they were unlikely to succeed. There were, however, a number of strategies and outputs for achieving change that could contribute to increasing safety for the population of interest. These were closely linked to community development strategies and needed greater acknowledgement in the evolution of the CIPPs. Critical to the development of the CIPPs were community capacity and the context in which the projects were operating. These conclusions are likely to apply to other projects in such settings, irrespective of the health outcomes sought.
Key words: community; evaluation; injury prevention
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Injury to children is a major health issue internationally [Roberts et al., 1995
; Svanström et al., 1995; Dowswell et al., 1996; Kemp et al., 1998; Kypri et al., 2000; Injury Prevention Research Unit (IPRU), 2001; Kypri et al., 2001; UNICEF, 2001], yet much of the injury suffered by children is predictable and preventable [World Health Organization (WHO), 1989; Towner et al., 1993; Langley, 1994; Pless, 1994]. Two approaches are commonly used in injury prevention. One focuses on the cause of injury, the other on the setting, where community involvement is usually sought (Baker, 1981; Gallagher et al., 1982; Glanz et al., 1990; Gielin and Collins, 1993; Ozanne-Smith et al., 1993; Schwarz et al., 1993; Davidson et al., 1994; Day et al., 2001). Interest in the latter approach for injury prevention has been increasing (WHO, 1989; Howat, 1995). The WHO Safe Community model is a well-known example (Schelp and Svanström, 1986; Svanström, 1987; Bjärås et al., 1990; Ytterstad, 1995; Coggan et al., 2000; Linqvist et al., 2002). Key components of this model are local ownership of the injury issue, collection of local injury data, and intersectoral collaboration (WHO, 1989; Howat, 1995). A set of criteria for accreditation with the WHO Safe Community collaboration were developed (WHO Safe Community Collaborating Centre, 1998).
In 1993, the Public Health Commission (PHC), a central government agency in New Zealand, funded the Royal New Zealand Plunket Society (Plunket) to establish two pilot community injury prevention projects (CIPPs) in communities with populations of <10 000. These CIPPs were to be separate geographically; one was to be in a community with a high M
ori population (New Zealand’s indigenous people) and at least one was to have an injury surveillance system. Unintentional childhood injury was the focus and the Safe Community model was offered as a guide. Plunket, a non-governmental organization dedicated to improving child health, was seen as a suitable organization, particularly as it had volunteers and staff already working in small communities. Two communities, Kawerau and Rangiora, met the selection requirements and accepted Plunket’s invitation to participate as pilot projects. In 1994, two larger community projects were also funded by the PHC, one of which has been described elsewhere (Coggan et al., 2000).
What works in a large community may not in a small one. Early development and evaluation of the Safe Community approach reflected initiatives in communities larger than those considered here, with the exception of Corkerhill in Glasgow (Roberts et al., 1995). New Zealand has numerous small communities and this evaluation was to address the establishment of CIPPs in this context. The following research questions incorporated the funder’s interests. How were the projects implemented? Why did they develop as they did? How appropriate was the WHO Safe Community approach in these small communities? What other factors might be critical to the development of these CIPPs? This paper reports on the implementation and development of these CIPPs, comments on aspects of the approach, and reflects on the critical factors that emerged in the evaluation.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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An externally conducted evaluation was undertaken over 3 years. Using a case study approach, each pilot CIPP was considered separately as ‘a unique contemporary event over which the evaluator has little control’ (Yin, 1994
). The process and impact of the implementation of the CIPPs were examined. The 12 criteria of the WHO Safe Community model provided the basis for the evaluation’s conceptual framework, but were reorganized into six themes: community context, ownership and participation, focus and planning, data collection, sustainability and external links.
As the evaluation progressed, inductive analysis of data collected indicated that additional factors were important in the implementation of the CIPPs and the parameters of these themes were expanded. Similarly, two further themes, ‘leadership’ and ‘management’, were identified as critical to development and were added to the framework, their inclusion supported by community studies elsewhere (Rothman et al., 1976; Rifkin et al., 1988; Bracht and Kingsbury, 1990; Bjärås, 1991a). Figure 1 summarizes the framework used.
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Data were collected from multiple sources including key informants, written documentation (which included minutes from meetings, official and unofficial reports, resources produced and letters) and archival material such as correspondence and background material from the time prior to the commencement of the evaluation. A variety of collection methods were used: informant interviews, focus group discussions, observation, and regular communication with the coordinators of the projects. Analysis was chronological and thematic. For reliability, the first two authors analysed the data independently (Miles and Huberman, 1984
). The findings from each CIPP were analysed separately before making any comparison. Approximately 40 semi-structured interviews were conducted in each community with the key informants, who included coordinators, committee members, implementers of specific strategies, community leaders, community observers, and those funding or managing the projects externally. The face-to-face interviews, conducted either by locally employed interviewers or by the first author, took ~1 h. The schedule was modified over time to reflect the projects’ development. A few of the informants were interviewed each year, allowing for more in-depth reflection on the changes observed over time. There was one refusal, and in all but one case permission was granted for the interview to be audio-taped. The transcript of each interview was available to the relevant respondent.
Two methodological issues emerged during data collection. The first was the importance of how data are collected from Mori participants. It was recognized that the data gathered belonged to the individual, and were given as a gift for the communal good. The collection, protection, transcription and use of the data were determined following advice from Mori researchers and consultation with members of the community. The interviewers employed to conduct the majority of the interviews in Kawerau were fluent in te reo (the Mori language) and had recognized links in the community.
The second issue related to the fear of evaluations. Patton noted participants’ perceived association between evaluation and attacks on a programme [(Patton, 1997), p. 10]. In this evaluation, fear might have contributed to a response bias since it might be perceived that voicing criticism could potentially result in negative consequences, such as funding being cut. In a small community, the potential to be personally identifiable as a critic is a risk. To counterbalance these concerns, it was emphasized that the role of the evaluation was to record and reflect on the lessons learnt by these pilots, for the benefit of these and other similar projects. Hearing the negative aspects was as important as recounting the successes. Some respondents noted the endorsement of the evaluation process by the coordinator, and acknowledged that this helped reduce their fears that adverse comments would be used against the project.
There were compromises in the data collection. Because interviewing was required on a casual basis only, retaining the same interviewers for 3 years was impossible. In Kawerau, having interviewers fluent in te reo and with local links was essential, and this took precedence over interviewing experience. While doing so may have reduced the detail collected, it was unlikely that as many would have been as willing to participate if an outsider had conducted their interviews.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Three chronological phases were identified in the development of the CIPPs. The early development phase lasted ~2 years from the inception of the Plunket contract. It revolved around an externally driven agenda: identifying communities to participate, establishing steering groups, appointing coordinators, and gaining a profile for the CIPP and injury prevention in general by promoting national safety campaigns locally. During the second phase, the transition, some sense of community development began to emerge with those supporting the projects seeking greater local ownership. The third phase was best characterized by gaining autonomy as the project styles began to reflect the local environments.
The following findings examine the evolution from the initial development phase to the CIPPs gaining autonomy, using the eight themes of the evaluation framework (see Figure 1
).
Community context
The two CIPPs, Safe Rangiora and SKIP (Safe Kawerau Kids Injury Prevention Project) were initiated with little knowledge of community priorities, capacity or previous injury prevention initiatives. The short time available in which to have an effect on injury contributed to the projects not undertaking a needs assessment of their community. Later in the evaluation period there was evidence of information relevant to a community profile being collected systematically. The following demographic detail provides some insight into contextual factors likely to have influenced the implementation of these CIPPs.
Rangiora had been a service centre for a productive agricultural region since the late 1800s. A century later, it was also a commuter suburb for the neighbouring city and a place to retire. Census data showed that in the 1990s, Rangiora’s population was increasing, unemployment was lower than the New Zealand average, 21% of the population were <15 years of age, and 7% of the population was Mori (Statistics New Zealand, 1992; Statistics New Zealand, 1997). Rangiora’s house prices were above the New Zealand average. The population was stable, and there was a sense of history in the area. The local authority expected the community to closely monitor its decision-making. The authority was committed to community development with a paid position established to foster it.
Kawerau was purpose-built in the 1950s for the workforce of a large forestry mill. Employment and housing needs changed, and from 1990 to 1996, Kawerau’s population decreased. It continued, however, to have a young population (30% under 15 years). Unemployment was high, as was the number of one-parent households. Fifty-eight per cent of the population was Mori (Statistics New Zealand, 1992; Statistics New Zealand, 1997), with many having affiliations outside the region rather than being local. In the mid 1990s, house prices were low compared with national prices. The high turnover of pupils within the Kawerau schools indicated that mobility of families was high. Involvement in local community affairs was low, with very few submissions made on local authority annual plans, for example. During the period of the pilot project, the local authority ceased to employ a community development officer.
Ownership/participation
At the inception, community participation was sought through consultation and a public meeting in each community. From the latter, steering groups were established. It was unclear, however, whether those who became members of these initial committees had the mandate to speak on behalf of the sector that others saw them represent. Local ownership of the CIPPs, therefore, was not necessarily secured. The initial agenda was set externally by the funder and by Plunket, despite the latter’s aspirations to operate a community development model. In addition, although the appointment process involved local people, the coordinators in each CIPP were seen to belong to the external management. At this initial phase, steering committee members were unsure of their role and their responsibilities to the project.
The CIPPs needed allies, and despite the limitations, networking between the CIPPs and other local organizations expanded. Safe Rangiora had a wide network involving government agencies and community organizations. SKIP sought to develop reciprocal support with local social programmes, but there were few government agencies in the community with whom to work. Kawerau had few people available to direct and deliver social programmes.
Community ownership was difficult to assess. One proxy measure used was the strength of committee members’ sense of ownership. This ownership changed considerably over the duration of the evaluation. By the end of the initial development phase, the external ownership had been challenged by the CIPP committees. Indicators that Safe Rangiora had gained autonomy were that the local committee felt it was in charge, that mechanisms were in place to monitor progress and that different levels of the community were involved, for example local councillors, paid council staff, representatives of school and health services, and community organizations. There were gaps in the representation, however, with no involvement from traditionally hard to reach sectors.
In Kawerau, SKIP’s committee members expressed a greater sense of ownership as the pilot project evolved. There were not, however, mechanisms established to facilitate collective responsibility or control. There was not a ready pool of volunteers in the community. Continuity was maintained, with the core of the committee remaining stable. This meant, however, that responsibility for the project could not be rotated among a gradually changing membership.
Focus and planning
The CIPPs could not implement the WHO criterion on determining their own priorities since their focus had been predetermined. While the resulting focus was likely to have been the same, the CIPPs lost the opportunity to learn by undertaking such an investigation. The initial focus on raising the profiles of the CIPPs and of injury prevention per se by undertaking ‘one-off’ safety campaigns was of little merit. To be beneficial, issues had to be addressed on an ongoing basis.
Before gaining autonomy, a crucial step for these CIPPs was the establishment of their planning processes. These processes strengthened the sense of committee ownership, gave a rationale for developing links, and helped develop a constructive working relationship with the funder. They ensured that the use of the limited resources was negotiated, and that they protected the paid coordinator from the demands for unplanned activities, which can occur in projects that are accessible to community members.
The WHO criteria emphasized the use of local data; however, priorities for these pilot projects were generally determined using national data, for two reasons. First, small populations are inadequate for identifying risk of injury with any degree of precision. Secondly, local data were difficult to obtain for the reasons outlined below. Local data were used, however, for some priority setting (e.g. SKIP identified that lacerations occurred more frequently in its community than national statistics would indicate). Environmental problems were identified and successful short-term strategies were developed to address them.
Different planning foci were noted. As it gained autonomy, Safe Rangiora planned for the future by consulting with the community, developing partnerships with new agencies and contracting its own research. Developing better public policy was the most effective mechanism it saw by which to achieve permanent injury reduction. The SKIP initiatives focussed on activities that would produce more immediate and tangible gains for the community, such as reducing broken glass, auditing and improving safety on public playgrounds, and assisting in the development of safer playgrounds for some pre-schools.
By the end of the evaluation, both CIPPs were contemplating expansion of their designated areas of activity. Within SKIP, questions were raised about changing its focus of unintentional injury, or indeed that of children. Safe Rangiora, with its increased alignment with its local authority, planned to extend geographically and expand its focus beyond 0- to 14-year olds.
Data collection
Each CIPP conducted a knowledge, attitude and behaviour survey in its community as part of its initial development phase. These surveys provided local knowledge on the awareness of injury and perceived concerns of the community useful for planning purposes. Unfortunately the design limited their contribution to understanding the incidence of injury or the impact of the projects over time.
A number of problems arose in attempting to develop an injury surveillance system in each community. Hospital discharge data were not particularly useful as there were few for childhood injury during any one year, and the details of the circumstances of these injuries were limited and not available in a timely fashion. Data that might provide sufficient detail to pinpoint potential local problems were sought from local health professionals. This approach had limited success. Not all general practitioners (GPs) in Rangiora were willing to use the collection system devised, and data were hard to obtain consistently. In Kawerau, although the GPs cooperated willingly, the data used were collected for another agency. Within a year, this agency had radically modified the system so that much of the useful information was no longer collected.
Collection of child injury data from primary sources in the community could not be undertaken systematically. In addition, an injury surveillance system was not seen as a useful tool with which to judge how well these CIPPs were progressing. Reducing injury remained the vision. Alternative measures for assessing the impact of activities were proposed, such as measuring the reduction of the risk of a particular cause of injury through a known intervention, for example by measuring the use of child restraint devices.
Local injury stories were used to motivate interest. Maintaining a regular exposure in the mass media to local injury events relevant to the priorities was difficult to sustain, however. In a small community, a car crash resulting in a child injury will be a rare event. Even if one occurs, those involved may be unwilling to publicize details and such publicity may not be in the family’s best interests. Utilizing events for which publicity can be obtained is an unfocussed exercise, however, and can distract from planned objectives.
Sustainability
Sustainability is critical for most community programmes, but long-term security was not a first priority for these CIPPs. The CIPPs were dependent on their coordinators, however, and ongoing funding was necessary to pay their salaries. Failure to secure ongoing funding would also undermine the investment already made by the community in injury prevention. The funding for these pilots was extended twice; first, for a further 2 years to allow the projects to achieve the outcomes sought, and again later so that the projects had time to seek further funding following the completion of the evaluation. This support provided a sense of continuity.
In New Zealand, injury prevention has traditionally been funded through central government, and significant funding from other sources was unlikely. Assistance did come from Rangiora’s local authority, which, while not offering to fund injury prevention, advocated strongly for the continuation of funding. SKIP had no equivalent champion. Kawerau had been used as a ‘guinea pig’ community before and pilot projects were viewed with some cynicism: ‘here today, gone tomorrow’. Without permanency, energy expended on pilots was wasted. The early promise of ongoing central government funding by the Health Funding Authority (HFA) was constructive, therefore, for maintaining momentum in Kawerau. Minor funding was accessed for specific initiatives, however, such as a sports injury prevention programme in Rangiora, and local resources were utilized, much of them ‘in kind’, for example staff time and resources.
External links
The WHO criteria emphasized international contact with Safe Community projects. During their initial phase, the CIPPs’ focus was on local development. SKIP created links with some existing child injury projects operating in small communities in areas relatively close geographically. This changed over time. Safe Rangiora sought contact with other Safe Community projects, and WHO Safe Community accreditation, reflecting an awareness of the political advantages of international recognition. SKIP sought links with projects in communities similar to itself, and consequently had little international contact. This may also have reflected an ethos against spending limited project resources outside the community, particularly attending conferences, when many of those with whom SKIP was working were relatively impoverished.
Leadership and management
Leadership and management, two factors not included in the WHO model, were essential to the evolution of these CIPPs. While these might be considered inherent in the criterion regarding sustainability, their importance to these CIPPs suggested that they should be considered separately.
Initially, leadership was provided by Plunket, with control exercised through the coordinators. During this phase, no local leaders or champions were apparent in the community. This did not change substantially over time for SKIP, where the coordinator remained the leader. In Rangiora, committee responsibility increased, leaders emerged from the internal management group, and local authority staff and elected councillors championed the cause.
Management was essential for development. No provision was made initially, however, for facilitating local ownership through good management. There was no direction to develop protocols and procedures for consultation, no locally derived planning and evaluation process, and neither management training nor budgeting opportunities were introduced. As Safe Rangiora moved towards autonomy, the expertise available ensured the establishment of procedures to facilitate ownership and participation.
Project management remained ad hoc for SKIP throughout the pilot phase. The external management became the responsibility of a regional non-governmental organization with experience in supporting community-based initiatives. Although it was preferable to have the external management closer to home, a number of the key elements were still missing for SKIP. SKIP had no local, high profile champion. The external management was still considered to be ‘outside’ the district. There was a reluctance to seek expertise from outside, and the travel time required to attend meetings discouraged some outside assistance. There was also a perception that committee members were already overloaded with existing community responsibilities that may have contributed to management not being shared.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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This evaluation focussed on aspects of developing and implementing injury prevention projects in small communities. The lessons learnt, however, are relevant to other initiatives in similar settings, irrespective of the health outcome sought.
The community development approach is not new to New Zealand (Shirley, 1979; Shirley, 1982; Duignan and Casswell, 1989), but the context in which it operates is important. This study identified that it was much easier for Safe Rangiora to implement the WHO Safe Community model than SKIP. Having experience, advice, and ongoing support for this approach made a considerable difference. Having structures of power open to influence (Barr, 1995) was critical to Safe Rangiora’s development.
The initial aim was for the projects to reduce the incidence of childhood injury. Attempting to develop injury surveillance systems in these small communities was time consuming and, in the end, did not provide statistically meaningful results. The size of the child population, the lack of existing collection systems and lack of resources made the undertaking difficult. Factors known to reduce the risk of injury, and the policy and environmental changes to address them, would have provided more useful outcome measures by which to evaluate the success of these CIPPs. Klassen et al.’s review of community interventions, for example, offers guidance on the effectiveness of safety practices that have been implemented (Klassen et al., 2000).
Local data have a role in motivating local action (Schelp and Svanström, 1986; Lund, 1987; Svanström, 1987), and may identify localized causes of injury amenable to intervention that do not feature in national statistics. Their limitations with respect to access, reliability and efficient use of resources must be acknowledged (Jeffs et al., 1993; Davidson et al., 1994; Benson, 1995). For example, in an effort to obtain sufficient data, the severity threshold for injury is lowered, and the data may lead to the rare, but potentially fatal, causes of injury being overlooked in favour of common injuries with little serious consequence.
The WHO Safe Community criteria have two complementary foci: injury prevention and community development. Both aspects were important to these projects. Missing from the CIPPs’ aims, however, was any formal expectation of obtaining outcomes related to community development, yet much of what was achieved during the pilot phase of these projects was related to this.
There has been considerable debate over definitions and values of community development, and evaluating outcomes can be problematic (Shirley, 1982; Hawe, 1994; Abbott, 1995). The level of community ownership, for example, was not easy to assess in this study. Who makes decisions in a community, and how those decisions are made, are considerations to take into account.
Work in the 1970s on community organization suggested that there was a preference for more concrete and immediate action in disadvantaged communities over longer term gain, which middle-income or upwardly mobile people may be satisfied with (Spergel, 1974). This conclusion offered a rationale for the differences in implementation observed in these CIPPs. SKIP emphasized tangible and physical environment outputs, while Safe Rangiora pursued more intangible activities such as seeking to influence local authority planning and policy. A second example was the external links made by each. SKIP sought practical support and advice from projects in similar communities, while Safe Rangiora also sought political support through international recognition.
The external agenda set by the funder and initial management may have slowed the early efforts to develop local ownership of the projects, but with the CIPPs’ increasing autonomy, that agenda became less of an impediment. This was closely linked to the positive responses of funder and management to the call for increased autonomy. This concurred with Dixon and Sindall’s observation that although initially a programme may be driven from outside, it does not have to remain so (Dixon and Sindall, 1994).
The budget for running these projects was small. The funding was inadequate for the initial aims, although these were modified later to reflect more realistically what was possible. When a community development approach is recommended, sufficient resources are needed to ensure there is the capacity in a community to achieve ownership of the problem, and apply effective solutions. Of considerable importance was whether the expectations of community member involvement was realistic, an issue noted previously (Bjärås, 1991b).
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CONCLUSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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The experience of implementing these two CIPPs suggests there are implications for similar initiatives internationally. Most importantly, projects such as these need to be within a community’s capacity to effect change. When changes in public policy at a national level are identified as the effective means to achieve change, it seems unreasonable to expect a small community project to make a difference. It was unlikely that the projects described here had an impact on their community’s rate of injury. They had, however, begun to raise awareness within sectors in their community who in turn could influence known risks for injury locally through, for example, developing healthier public policy or creating safer environments.
These conclusions do not absolve projects of the responsibility to achieve the outcomes sought; in this case to contribute to a reduction in injury. They do reiterate that for success, projects in small communities, just as those in larger ones, need to undertake strategies known to be effective in addressing the risks concerned. In smaller communities especially, the expectations of what can be achieved and of the processes required to reach identified outcomes need to be realistic. Given the importance placed on ‘the community’, greater recognition of the processes that enable a community to make its contribution is required.
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ACKNOWLEDGEMENTS |
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The authors would like to acknowledge the assistance of the managers, coordinators and community members involved in these projects, for the collection and analysis of the data, and for their comments on this paper. The evaluation was funded by the Health Funding Authority of New Zealand. The Injury Prevention Research Unit is funded by the Health Research Council of New Zealand and the Accident Compensation Corporation.
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