| | Public health, emergency medicine, and the community interfaceAbstract Physicians practicing in emergency care settings are likely to see the broadest spectrum of pediatric injuries in relation to other health care professionals. Whether it is a child in a motor vehicle collision requiring admission to an inpatient trauma service, or a young soccer player receiving a splint for a sprained ankle, emergency physicians are uniquely positioned to be involved in the development of systematic approaches to injury prevention. The natural interface with the community that occurs in the provision of emergency care necessarily mandates that injury prevention strategies incorporate community-based approaches and intervention models. This article examines the components of community-based strategies for injury prevention, and identifies the inherent implementation challenges through discussion of selected emergency medicine-led initiatives.
INJURY REMAINS THE LEADING CAUSE of death and disability for children older than one year of age.1 National hospital ambulatory medical care survey data cites that in 1999 over 37 million emergency department visits were injury related, 40% of those for patients 24 years of age or younger.2
The public health approach and emergency medicine  Before engaging in any discussion of injury prevention and control, it is important that the rudiments of the public health approach first be articulated. The public health approach is a time-tested model that has been successfully employed in the elimination of specific communicable diseases and the reduction of behaviors deleterious to human health, such as tobacco use. Its importance cannot be over-emphasized, as its scientific applications are the building blocks upon which successful community-based interventions of any type are structured. The steps of the public health approach proceed sequentially, and often tediously, as they build upon data and lessons learned through each successive step (Fig 1). Intervention development, analysis, and evaluation are supported by re-evaluative feedback loops that provide opportunity for community input and response. Emergency care settings form a critical foundation for implementation of the public health approach. Problem definition: utilizing the emergency department Before an intervention can even be conceived, it is imperative that the issues being addressed are fully described both quantitatively and qualitatively. For instance, in the case of community violence prevention, baseline intentional injury rates specific to the target population must be calculated. Quantification of the injuries must be supported by a description of the patterns and circumstances contributing to the causal sequence of an injury event. The painting of such a picture is best achieved through active emergency department (ED)-based injury surveillance. Proxy measures such as mortality statistics and trauma registry data, are biased toward the most severe injury events, and thereby estimate only a subset of the overall injury burden in a community.1 The full breadth of a community’s injury problem is best appreciated through tracking of both fatal and nonfatal injuries, and of patients admitted to the hospital, as well as those discharged from the ED. There have been several examples of successful population-based active injury surveillance systems conducted through EDs.2, 3, 4, 5 These studies have provided valuable information regarding community-specific injury patterns, describing unique risk factors such as weapon carrying, intentionality, and recidivism.6, 7 Coupled with the descriptive capability of geographic information systems for coding and mapping, active ED-based surveillance can help to direct interventions to specific neighborhoods or populations in a timely and targeted manner.8 There are obvious limitations to the detail and accuracy that ED surveillance can provide, in that emergency treatment records are all too often incomplete or poorly documented.9, 10 An additional method for gathering information to define the problem is through the conduction of key informant interviews. This methodology can be a particularly effective way of filling in the contextual gaps relative to circumstances and causal sequencing that chart abstraction surveillance cannot always provide. The information learned through such interviews can also serve to validate the reliability of chart abstraction data. Further, a sufficient, representative sampling of both injured and non-injured patients can help to identify unique risk factors that can provide a nidus for a targeted intervention. ED-based interviews also bring providers and community members literally face-to-face in the acute care setting, offering the opportunity to implement brief point-of-contact interventions. Such behavior change counseling sessions have demonstrated short-term efficacy as secondary preventive measures in certain adolescent injury risk behaviors including bicycle helmet and seat belt use.11 Emergency medicine has an inherent social obligation to capitalize on “postvention” opportunities and to investigate creative and effective methods for taking advantage of them. Problem definition: beyond the emergency department Moving further along the continuum of qualitative problem definition is the convening and analysis of community-based focus groups. Long used as a staple in private sector marketing research, focus groups have only recently gained favor as a useful tool in traditional biomedical research.12, 13 Focus groups are advantageous when investigating issues that are ill defined or complex, thereby rendering this methodology particularly well suited for injury prevention research. The conduction of focus groups in community venues brings the problem definition phase of the public health approach directly into the community, empowering its members to participate as change agents in the prevention process. Especially when dealing with adolescents and young adults, this empowerment is a crucial step towards community integration at the brainstorming and developmental stages of an intervention.14, 15 Working with the focus group methodology also presents an opportunity for multidisciplinary cooperation and cross-fertilization of ideas. Social scientists, including psychologists and anthropologists, are generally more facile with the ethnographic and nominal group techniques necessary to properly collect and analyze focus group data, and should be recruited to collaborate with injury prevention researchers whenever possible. The rich combination of quantitative and qualitative data provides a comprehensive and complimentary picture of what’s truly going on outside the doors of the ED. Only through this baseline characterization of the problem at a community level can risk factors be identified, and interventions subsequently developed, tested, and evaluated. Further, only with an accurate surveillance system in place can the efficacy of interventions be assessed over time through the continued measurement of injury markers and trends. Defining the problem and getting started can be an arduous and resource-heavy undertaking, but in the struggle with population-based injury control, we have to accept the sobering reality that the race is not a sprint, but a marathon. Establishing the community context Communities are commonly understood to represent geographic areas with defined boundaries, which are generally constituted by a group, or groups, with shared characteristics, interests, values, and norms.16 This definition creates an image of a staid, well circumscribed, homogeneous collection of individuals, who, from an intervention standpoint, can be easily targeted. In actual fact, communities are fluid, diverse, and dynamic, with ill-defined boundaries and shifting norms. In order to effect successful community-based, community-wide prevention programs, the adoption of an organizing strategy that ensures community investment in, and ownership of, the intervention effort must be employed. The incorporation of these elements is an essential part of establishing credibility and trust as interventionists move out of the ED and into the community. Indeed, programs in which the community is the site rather than the source of an intervention development are doomed for failure.17, 18 In order to operationalize the intervention development, implementation, and evaluation steps of the public health approach with a community-based orientation, several important programmatic elements must be incorporated. The recruitment of a community advisory board is perhaps the first and most critical step. The ability to effectively recruit such a body presumes a pre-existing presence in the community perhaps built upon relationships established through service delivery or previous partnerships. It is important that any committee of community constituents is truly representative of the target population. For instance, if a project is targeted toward youth, it is imperative that an advisory group composed of young people is formed. Recruitment should not only capture traditional community leadership, such as clergy, educators and public officials, but should be aimed at including local grass-roots organizers as well. The latter group may be more obscure and not as immediately identifiable, but the value that such individuals can bring to a community level effort is well worth the block to block canvassing that may be required. The community advisory process needs to begin along with, if not before, the early stages of project development because the regular input of community partners will frame the actual design of an intervention. Such input must be integrated into project design as a standard component of ongoing monitoring and evaluation through periodic update meetings, data response sessions, and focus groups. Every effort should be made to make this process community “friendly” by holding meetings after work or school, and at venues that are convenient for the committee members. The investment of the individuals who commit themselves to this process is a valuable programmatic resource/requirement, and their time should be compensated accordingly. Since the mid-1990s, the injury prevention research group based in the Center for Health Services and Community Research at Children’s National Medical Center in Washington, DC has been refining a community-based approach to intentional injury prevention. The framework was built upon an emergency medicine foundation and has been implemented across a series of local and regional prevention research efforts.19, 20, 21, 22 The schematic model incorporates both the linear scientific steps of the public health approach and the more dynamic elements of community integration (Fig 2). 23 Cultural competence Any project advisory process should reflect the ethnic diversity of a community as can best be achieved. All aspects of project development, design, and implementation need to account for the unique cultural characteristics that are woven into the fabric of every community. Further, project leadership must personally embrace and insist upon the application of the principles of cultural competence as a primary ingredient for project success (Fig 3). Formally defined as the set of congruent behaviors, attitudes, and policies which enable a system, program, or professional to work effectively in cross-cultural situations, cultural competence is a developmental process that begins with a commitment to purposeful self-examination of one’s own cultural beliefs and values.22 Only through complete awareness and acceptance of the importance of culture on communication and service delivery can professionals managing community-based efforts begin down the path of building cultural competence.25 Such competence is best viewed as a goal toward which a program or individual must definitely strive but can realistically never fully achieve. No matter how vigilant one is toward acknowledging the dynamics of difference, building a cultural fund of knowledge, and subsequently adapting these skills to service delivery, there will always be room for growth.26 One of the key strategies towards achieving this objective is to look to the community itself as a ready resource for hiring committed and capable individuals to constitute project staff. This will not only facilitate direct interaction with community members, but can also build capacity within the community through training and development and skills acquisition. Such a strategy also fuels empowerment through the realization that the impetus for change can come from individuals and resources within the community itself. This kind of up front investment on the part of project leadership instills receptivity and acceptance, and helps to foster a sense of mutual problem ownership. It is clear that in these times of limited resources, partnerships leading to community capacity building, self-help, and empowerment are the only way to institutionalize and sustain community-based prevention efforts. Project UJIMA is an example of an emergency medicine-initiated effort that has capitalized on the cultural assets of the community being served. In order to address the disproportionate burden of intentional injuries borne by young men of color, physicians from an urban pediatric ED in Milwaukee created an intervention that was predicated upon the seven principles of Kwanzaa, a holiday period celebrated in late December and widely acknowledged in the African-American community.27 Unity, self-determination, collective work and responsibility, cooperative economics, purpose, creativity, and faith were all woven into a program whereby intentional injury victims were actively and directly linked with community-based support services through peer facilitators stationed in the ED.28 The program has moved positively towards its principal goal of reducing injury recidivism in that community.29 Community participatory research Community participatory research is described as a systematic inquiry undertaken in collaboration with those being affected by the issue being studied, for the purpose of education, taking action or effecting social change.30 Best practices in the area of prevention science focus on just such an approach; one that takes a global view of the problem. Effective intervention efforts aim to change the social norms that will eventually lead to collective behavior change rather than identifying the individual as the exclusive unit of evaluative measure.31 In that regard, injury prevention research presents many challenges to the physician-investigator that are distinct from the classical bio-medical model of clinical research. Methodologic issues The most effective interventions in childhood injury prevention occur outside the hospital in environments where children and families spend most of their time.32 In addition, the outcomes of most importance may not be as cleanly delineated or easily obtained as with traditional hospital-based clinical research. For example, one can obtain an objective measure of oxygen saturation after treatment with nebulized albuterol. However, to truly assess the effectiveness of a bicycle helmet use campaign, instruments that measure changes in knowledge, attitudes, and behaviors are as critical a component of evaluation as is quantifying the bicycle-related head injury rate.33, 34, 35 Further, community surveillance methods must be granular enough to assess important intermediary and quality of life outcomes such as overall morbidity reduction, return to school, or return to functional baseline. Unlike traditional research, in which the study design is determined before the project begins, integrating the community often delays this step. Commonly, the research plan will need to evolve as a community needs assessment is conducted, or be changed as a function of the community advisory and review process. Ultimately, total community buy-in is necessary before a final plan can be delineated. Differing views about the purpose and goals of the research can also pose methodologic challenges.36 Community partners are often more service-oriented and product driven vis-ă-vis their role in a research collaboration, while academicians necessarily tend to seek rigor and validity as the endpoint for the methods being employed. As an inherent inevitability of such collaborations, each partner may need to support a range of deliverables in order to demonstrate overall project success. Community agencies may be looking for the number of children served by an intervention (process evaluation) while academic partners want to measure the impact of the intervention on behavior or injuries (outcome evaluation). For example, community partners may want to implement an intervention program for all children in a given environment while academic partners want to target, or randomize to, a select experimental group, identifying a control population for comparative analysis.37 There may be concern on the part of community collaborators that such an approach seems arbitrary, preferential, and dismissive. In this situation, it is important that academic partners bear responsibility for the ongoing education of all collaborators in the benefits of rigorous evaluation and the steps necessary for successful completion.38 This approach necessitates building the trust, respect, credibility, and competence discussed earlier and requires being “on the ground” long before the first pilot phase of a community-based research intervention can be started. Partnerships Emergency physicians interested in injury prevention represent the health professionals most opportunely positioned to develop and coordinate research collaborations with invested community-based entities. Among the most logical institutional partnerships include linkages with fire and emergency medical services (EMS), law enforcement, schools, and municipal departments of public health. Developing partnerships with community members and grass roots organizations assists the physician in assessing the needs of the community as well as the existing resources.39 Unfortunately, communities have often been taken advantage of and can be skeptical of establishing of such partnerships. Concerns around trust, respect, and the distribution of power are often the largest challenges. These can be overcome by clearly defining each partner’s goals and objectives as a member of the collaborative. An example of a successful partnership is the Southern California Risk Watch Coalition, an initiative led by physicians from a local municipal ED.40 In 1998, surveillance data from the ED revealed that almost a child a day from the surrounding communities was being treated for a preventable injury-related problem. Concurrently, local schools were faced with the need to provide injury prevention education to students, but had no training capacity in this area. Los Angeles County Fire and EMS had a professional mandate to provide public education around safety, but were limited in their time and ability to connect with children. The Coalition was created to address the community need for child safety while simultaneously addressing the individual needs of each partner. Key to the group’s success has been the development of mutual respect, close communication, and pointed attention to the distribution of authority. The Southern California Risk Watch Coalition has been in existence since 1998 and has successfully implemented the comprehensive Risk Watch injury prevention curriculum in seven communities reaching over 3,000 children.41 Human subjects concerns Any type of activity in which the goal is research should be approved by the academic entity’s institutional review board (IRB). This can be a daunting process. However, with community-based research that has a public health focus, many prevention projects can be framed as minimal risk to community members. The minimal risk category still obligates the investigators to obtain informed consent from participants, although the IRB review process can often be expedited. Projects that assess behaviors observable in public, involve completion of surveys in which anonymity is assured, or those that are limited to secondary data analysis are examples of projects that may qualify for exemption from informed consent.42 Regardless of risk category, it is always prudent to fully address all potential human subject vulnerabilities in the research plan and establish contingencies for dealing with them. For instance, a project that investigates injury burden in a pediatric population must always account for the potential disclosure of child maltreatment during the course of data gathering. This is obviously reportable, and all parties involved must be fully aware of the consequences and procedures associated with such disclosure. There may be other circumstances that present during the course of inquiry, while not necessarily legally reportable, may pose a public safety risk that investigators have to be prepared to weigh and address. Revelation of weapon-carrying behavior is just such an example and represents the kind of issue that investigators and community partners should discuss proactively as part of research collaboration. In fact, undertaking a formal community consultation in advance of a proposal submission provides a mechanism whereby health services researchers can facilitate the education of IRB’s about the complexities of organizing community-based research. The injury free coalition for kids There is a growing body of literature describing and detailing community-based injury prevention projects that have emanated from hospital-based efforts, many specifically led by emergency medicine physicians.43, 44, 45 Arguably the most successfully replicated example of a comprehensive, data driven, community-specific injury prevention programmatic model has been the Injury Free Coalition for Kids (IFCK) program. Originated as the Harlem Hospital Injury Prevention Program, and with the help of funding from the Robert Wood Johnson Foundation, IFCK sites have currently been established in 27 communities across the country, with a goal of 40 by the end of 2003.46 The evolution of the IFCK model is a case study that illustrates the major principles that have been discussed in this paper, and it is instructive to have a brief historical understanding of its roots and development. The Harlem Hospital Injury Prevention Program (HHIPP) was established in 1988. The goals of the project were focused on an overall reduction of severe injuries to school-aged children and adolescents from the major causes of childhood injury: falls, motor vehicles, assaults, and firearms.47 The strategy in Harlem is multidimensional: the program components include (1) improving the safety of the environment through the creation of safe parks and playgrounds; (2) supporting the development of the community through educational programs for children and adults on health, safety, and prevention issues; and (3) providing safe and supervised activities for children and adolescents including little league baseball, soccer, art, and dance.48 The theoretical framework for the development of the strategy is based on the basic intervention principles espoused by Haddon, and firmly embodies the public health approach.49 The HHIPP serves as the lead coordinating agency for a coalition of community-based organizations. This coalition is composed of groups either focused on community empowerment through education and self-help, or on the provision of safe activities and play environments. The implementation of these activities is not only conducted through these grass-roots organizations, but also supported by the New York City governmental agencies overseeing parks, transportation, and health.50 Through a comprehensive injury surveillance system, the Northern Manhattan Injury Surveillance System, the investigators had established baseline pediatric injury, admission, and mortality incidence rates for a full five-year period before the intervention. The surveillance system also captured a neighboring non-intervention community, so the investigators designed their epidemiologic evaluation to analyze ecologic change over time as a result of intervention in the study community, as well as controlled comparison to the neighboring community. Post-intervention incidence of severe violent injuries (assaults and gunshot wounds) over the three year period, 1989-1992, decreased by nearly half when compared to the five year pre-intervention period, 1983-1988. In the non-exposed neighboring community, the incidence of assaults and gunshot wounds continued to trend upward over the same period of time.51 Overall, there was a 44% reduction in risk for all injuries targeted by the HHIPP over the period of analysis.52, 53 The HHIPP/IFCK model has obviously benefited from energetic physician leadership, proven efficacy, and committed partners. However, it’s long-standing continual presence in the community, coupled with ongoing resources to support that presence are the overriding features to which all community-based efforts need to strive. In summary, the most promising strategy for reducing the burden of injury on our children in sustainable and indelible fashion is to take the science to the street. Only through the combination of environmental and social change can we truly expect to positively influence individual behavior across populations and for generations to come. Clinical researchers and interventionists must therefore apply the lessons learned from traditional biomedical and hospital-based models to the community setting. This translation is not an easy task. It typically requires long-term planning and commitment, and the types of scarce resources that must compete with other public health priorities. However, by recognizing and capitalizing upon the unique interface opportunities afforded in the emergency care environment, significant injury intervention and prevention possibilities exist. It behooves emergency medicine leadership to acknowledge the specialty’s public health responsibilities in this area, and to facilitate and support the involvement of interested constituents. 24 References 1.
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Pediatrics. 1999;103:e74. a Children’s National Medical Center, Washington, DC, USA b Division of Emergency Medicine, and the George Washington University Schools of Medicine and Public Health, Washington, DC, USA  Address reprint requests to Joseph L. Wright, MD, MPH, Emergency Medicine and Trauma Center, Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010-2970 USA
PII: S1522-8401(03)00026-0 doi:10.1016/S1522-8401(03)00026-0 © 2003 Elsevier Inc. All rights reserved. | |
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