A cost-benefit analysis of the community-based injury prevention programme in Motala, Sweden--a WHO Safe Community

Community-based relapse prevention for opiate dependents: a randomized community controlled trial

Relapse prevention (RP) programs mainly focus on patients and their families; however a patient's community can also play a significant role in RP. A randomized-controlled-trial was conducted among opiate-dependents discharging from residential abstinence-based treatment programs to assess the effect of a community-based relapse prevention program (CBRP) on the RP. Seventy-one participants were consented and randomized into CBPR (n = 35) or treatment-as-usual arms. Developing and implementing CBRP, social-workers and peer-group counselors facilitated and advocated thirty-six RP projects across 7 communities during a three-month follow-up period. Negative-drug-tests, 45 and 90 days after discharge from residential programs were considered as the main outcome. Abstinence rates were significantly greater for patients who received CBRP in comparison to the subjects in the treatment-as-usual arm at 45 days (27 and 20, P < 0.004) and 90 days (27 and 21, P < 0.007) after discharge. CBRP was an effective method for RP among opiate-dependents after being discharged from the residential programs.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Safe communities in China as a strategy for injury prevention and safety promotion programmes in the era of rapid economic growth

Due to its rapid economic development, China is facing a huge health, social, and economic burden resulting from injuries. The study's objective was to examine Safe Communities in China as a strategy for injury prevention and safety promotion programmes in the era of rapid economic growth. Literature searches in English and Chinese, which included grey literature, were performed on the Chinese Journal Full-text Search System and Medline, using the words "Safe Community", "injury", "economics", and "prevention". The results showed that the existing 35 recognized members of the International Safe Community Network have not placed due emphasis on suicide prevention, which is one of the leading problems in both rural and urban China. A few groups, such as children, the elderly, cyclists, and pedestrians, have received due emphasis, while other vulnerable groups, such as migrant workers, motorcyclists, students, players, and farmers have not received the necessary attention from the Safe Community perspective. As the evidence describes, Safe Communities in China can be a very effective strategy for injury prevention, but four aspects need to be strengthened in the future: (1) establish and strengthen the policy and regulations in terms of injury prevention at the national level; (2) create a system to involve professional organizations and personnel in projects; (3) consider the economic development status of different parts of China; and (4) intentional injury prevention should receive greater attention.

Systematic review and quality assessment of economic evaluation studies of injury prevention

OBJECTIVE

To review and assess the quality of economic evaluation studies on injury prevention measures.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases searched included Medline (Pubmed), EMBASE, Web of Science, PsycINFO, and Safetylit.

INCLUSION CRITERIA

Empirical studies published in English in international peer-reviewed journals in the period 1998-2009. The subject of the study was economic evaluation of prevention of unintentional injury. Cost-effectiveness (CEA), cost-benefit (CBA) and cost utility (CUA) analyses were included.

METHODS

Methodological details, study designs, and analysis and interpretation of results of the included articles were reviewed and extracted into summary tables. Study quality was judged using the criteria recommended by the Panel on cost-effectiveness in health and medicine and the British Medical Journal (BMJ) checklist for economic evaluations.

RESULTS

Forty-eight studies met the inclusion criteria of our review. Interventions assessed most frequently were hip protectors and exercise programs for the elderly. A wide variety of methodological approaches was found, including differences in type of economic evaluation, perspective, time horizon, study design, cost categories, effect outcomes, and adjustments for timing and uncertainty used. The majority of studies performed a cost-effectiveness analysis from a societal perspective with a time horizon of one to five years, in which the effect was expressed in terms of injuries prevented and only direct health care costs were included. Most studies deviated from one or more of the Panel recommendations or BMJ guidelines; e.g. not adopting the societal perspective, not including all relevant costs, no incremental analysis.

CONCLUSIONS

This review has shown that approaches to economic evaluation of injury prevention vary widely and most studies do not fulfill methodological rigour. Improving quality and harmonization of economic evaluation studies in the field of injury prevention is needed. One way of achieving this would be to establish international guidelines on economic evaluation for injury prevention interventions, based on established economic evaluation checklists, to assist researchers in the design and reporting of economic evaluations.

Cost-effectiveness of injury prevention - a systematic review of municipality based interventions

Background

Injuries are a major cause of mortality and morbidity which together result in avoidable societal costs. Due to limited resources, injury prevention interventions need to demonstrate cost-effectiveness to justify their implementation. However, the existing knowledge in this area is limited. Consequently, a systematic review is needed to support decision-making and to assist in the targeting of future research. The aim of this review is to critically appraise the published economic evidence of injury prevention interventions at the municipal level.

Methods

A search strategy was developed to focus a literature search in PubMed, Embase, Cochrane and NHS EED. Studies were eligible for inclusion if they were economic evaluations of injury prevention interventions that could be implemented by municipalities; had a relevant comparison group; did not include any form of medication or drug use; and were assessed as having at least an acceptable quality from an economic point of view. Articles were screened in three steps. In the final step, studies were critically appraised using a check-list based on Drummond's check-list for assessing economic evaluations.

Results

Of 791 potential articles 20 were accepted for inclusion. Seven studies showed net savings; four showed a cost per health score gained; six showed both savings and a cost per health score gained but for different time horizons and populations; and three showed no effect. The interventions targeted a range of areas such as traffic safety, fire safety, hip fractures, and sport injuries. One studied a multi-targeted community-based program. Only six articles used effectiveness data generated within the study.

Conclusions

The results indicate that there are injury prevention interventions that offer good use of societal resources. However, there is a lack of economic evidence surrounding injury prevention interventions. This lack of evidence needs to be met by further research about the economic aspects of injury prevention interventions to improve the information available for decision-making.

The 'WHO Safe Communities' model for the prevention of injury in whole populations

BACKGROUND

The World Health Organization (WHO) 'safe communities' approach to injury prevention has been embraced around the world as a model for co-ordinating community efforts to enhance safety and reduce injury. Approximately 150 communities throughout the world have formal 'Safe Communities' designation. It is of public health interest to determine to what degree the model is successful, and whether it reduces injury rates. This Cochrane Review is an update of a previous published version.

OBJECTIVES

To determine the effectiveness of the WHO Safe Communities model to prevent injury in whole populations.

SEARCH STRATEGY

Our search included CENTRAL, MEDLINE and EMBASE, PsycINFO, ISI Web of Science: Social Sciences Citation Index (SSCI) and ZETOC. We handsearched selected journals and contacted key people from each WHO Safe Community. The last search was December 2008.

SELECTION CRITERIA

Two authors independently screened studies for inclusion. Included studies were those conducted within a WHO Safe Community that reported changes in population injury rates within the community compared to a control community.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. Meta-analysis was not appropriate due to the heterogeneity of the included studies.

MAIN RESULTS

We included evaluations for 21 communities from five countries in two geographical regions in the world: Austria, Sweden and Norway, and Australia and New Zealand. Although positive results were reported for some communities, there was no consistent relationship between being a WHO designated Safe Community and subsequent changes in observed injury rates.

AUTHORS' CONCLUSIONS

There is marked inconsistency in the results of the studies included in this systematic review. While the frequency of injury in some study communities did reduce following their designation as a WHO Safe Community, there remains insufficient evidence from which to draw definitive conclusions regarding the effectiveness of the model.The lack of consistency in results may be due to the heterogeneity of the approaches to implementing the model, varying efficacy of activities and strategies, varying intensity of implementation and methodological limitations in evaluations. While all communities included in the review fulfilled the WHO Safe Community criteria, these criteria were too general to prescribe a standardised programme of activity or evaluation methodology.Adequate documentation describing how various Safe Communities implemented the model was limited, making it unclear which factors affected success. Where a reduction in injury rates was not reported, lack of information makes it difficult to distinguish whether this was due to problems with the model or with the way in which it was implemented.

Evaluation of community-based injury prevention programmes: methodological issues and challenges

The evaluation of comprehensive community-based injury prevention programmes is complex and poses many methodological challenges. There is little consensus in contemporary literature about the most appropriate methods of evaluating these programmes. This study employed a systematic literature review to examine evaluations of 16 community-based injury prevention programmes with regard to key methodological issues and challenges. Three aspects of the evaluated programmes were analysed: assessed elements (context, structure, process, impact, and outcome); study design; and methodological issues addressed. The results showed that context, structure and process assessments were the most neglected aspects of the evaluation studies. The programmes were typically described with minimal discussion of how the context may have influenced the effectiveness. The process (activities) was described rather than evaluated against appropriate standards of comparisons. Impact evaluations adhered more closely to documented guidelines, but half of the evaluations did not include impact variables. Outcome evaluations focused on injury incidence. Most evaluations employed some qualitative methods, but the vast majority of methods used were quantitative. This study indicated that the quasi-experimental study design has become an accepted norm for the evaluation of community-based injury prevention programmes. Most of the evaluations contained explicit details of the methodology used and of the choices related to the methodology. While threats to internal validity were identified in most studies, problems related to external validity and construct validity were largely overlooked by the evaluators.

Impact of social standing on sports injury prevention in a WHO safe community: intervention outcome by household employment contract and type of sport

OBJECTIVES

As physical activity is promoted as part of a healthy lifestyle, sports injuries are becoming an important public health concern in many countries. The objective of this study is to investigate rates of sports injuries before and after implementation of a WHO Safe Community program.

METHODS

Sports injury data were collected pre- and post-implementation from all individuals below 65 years of age during 1 year in the targeted municipality (population 41,000) and in a control municipality (population 26,000). A quasi-experimental design was used and individuals were divided into three categories based on household relationship to the labour market.

RESULTS

There were no differences between socio-economic categories regarding pre-intervention injury rates. No statistically significant post-intervention changes in injury rate were observed in the control area or among any females in either area. In the intervention area, a statistically significant (p = 0.011) decrease in injury rate was observed among male members of households in which the vocationally important member was employed. A statistically significant decrease was observed in injuries sustained in team sports among male members of households in which the vocationally important member was employed (p = 0.001) and among members of households in which the vocationally important member was self employed (p<0.05).

CONCLUSIONS

The study indicates areas for improvement in the civic network based WHO Safe Community model. The results show that females, participants in individual sports, and members of non-vocationally active households were less affected by the interventions. These facts have to be addressed in planning future community based sports injury prevention programmes and their evaluations.