Journal Issue: Unintentional Injuries in Childhood Volume 10 Number 1 Spring/Summer 2000
Community-based interventions have been successful in some areas of childhood injury prevention. Specifically, the increased use of bicycle helmets and motor vehicle safety seats among children has been associated with effective community-based programs. For other injury areas—including child pedestrian safety, adolescent alcohol use and vehicle safety, and general safety campaigns—the benefit of community-based strategies is less evident. Lack of success in these areas may be attributed to poorly designed and implemented programs, inadequate research methodology, or the inherent inability of community-based strategies to alter safety practices or reduce injury outcomes. For some safety behaviors and target populations, such as motor vehicle restraint use among adolescents, well-designed programs that include multiple strategies and are grounded in an accepted theory of behavior change simply have not been tested in community settings. For other areas, such as pedestrian safety among young children, there is evidence that community-based educational interventions alone are insufficient to consistently alter young children's behavior in traffic situations. Community-based approaches focused on engineering modifications to increase road safety may be more effective, but have not been rigorously evaluated.
Future community-based interventions should adopt the key elements common among the successful programs in this systematic review. Education remains an important component of community-based injury prevention efforts. All too often, though, education is viewed in only one dimension: the didactic presentation of information to affect knowledge. The key assumption—that changes in knowledge automatically result in changes in behavior—is not supported by research. Instead, changes in knowledge must be accompanied by improved skill, changes in social norms, a supportive environment, and reinforcement that encourages behavior change. These aims may be difficult to achieve in community programs, especially given the limited time of most interventions.
In addition to education, effective programs use a broad array of other strategies and rely on existing community organizations and infrastructure, such as schools, the media, and/or sponsorship by private industry (that is, to reduce costs of safety devices). The selection of strategies should be based on previous evidence identifying factors most amenable to change. Finally, messages should be tailored to address as many community groups as possible within the target audience.
Perhaps the most important challenge in designing community-based interventions is the use of scientific evaluation. Recent evidence has established that nonrandomized designs yield an overestimation of benefit compared with randomized designs,56 and many community interventions fail to employ randomization, even when this approach is feasible.1 Randomization can be achieved by randomly assigning groups of individuals (for example, schools) or entire communities to control or intervention conditions. Cluster randomization, a technique that allows for randomization of communities, should be used more frequently.57 It is only when such rigorous designs are used that society will be able to determine where best to invest resources in community-based interventions.
The community-based approach to injury prevention fits in well with the public health priority of improving the health of population groups. For communities to maximize the potential benefit of this approach, they must become active participants in injury prevention efforts. Many studies included in this systematic review indicate that community organizations have shown the commitment, the desire, and the ability to share the burden and responsibility for reducing childhood unintentional injuries. In consultation with community leaders and organizations, future studies should continue to test the effect of well-designed community-based approaches aimed at improving safety behaviors and reducing injuries among children and youths.