The Social Determinants Of Injury Resource Guide

May 2012

Social Determinants of Injury Resource Guide

Developed for: Understanding the Injury Prevention Resource and Learning Needs of CAPC/CPNP – Phase Two by the Atlantic Collaborative on Injury Prevention (ACIP) Table of Contents

Introduction to Resource Guide Page 3

Hosting a Social Determinants of Injury Workshop Page 4

The Social Determinants of Injury – Guide to the Powerpoint Presentation Page 5

 Injury in Canada

 Income and Income Distribution

 Employment and Working Conditions

 Education and Literacy

 Housing

 Gender

 Urban and Rural Environments

 Children (1-14 years)

 Adolescents

 Seniors

 Aboriginal Communities

 LGBT Community

 Best Practice Considerations

Social Determinants of Injury Resource Guide | 2  Primordial Prevention

 Strong Social Policy

Workshop Template Page 17

Workshop Facilitator’s Guide Page 18

Workshop Evaluation Page 20

References Page 21

Social Determinants of Injury Resource Guide | 3 Introduction to the Social Determinants of Injury Resource Guide

In 2012 the Atlantic Collaborative on Injury Prevention (ACIP) released a report entitled The Social Determinants of Injury. Recognizing that much is known about the social determinants of health and how they relate to health issues such as chronic disease, the purpose of the report was to assemble current information on the link between social and economic conditions and injuries. The results are conclusive – Canadians are not affected equally by injuries. Children in particular face greater risk of severe or fatal injuries in the presence of certain social and economic conditions such as low income.

Recognizing the role that social and economic conditions play in children’s health, safety, and well-being, the Community Action Program for Children (CAPC) and the Canadian Prenatal Nutrition Program (CPNP), through the National Projects Fund project Understanding the Injury Prevention Resource and Learning Needs of CAPC/CPNP –Phase Two Implementation, have requested the development of the following resource for use by program sites throughout Canada. Funding for this project was made available through the Public Health Agency of Canada's CAPC/CPNP National Projects Fund. The views expressed herein do not necessarily represent the view of the Public Health Agency of Canada.

The goal of the project is to develop/adapt child injury prevention training and resources that will be useful and accessible for CAPC/CPNP staff as they work with vulnerable families across Canada. A number of needs and gaps were identified in the first phase of this project, one of which was the relationship between the determinants of health and injury. This resource is designed to provide information about the social determinants of injury along with a framework for hosting a workshop on the topic. It includes a Power Point Presentation with accompanying information about the social determinants of injury, a template workshop plan, a description of workshop techniques, and a workshop evaluation form.

You may note throughout this resource that there is significant overlap between the various social and economic conditions that are linked to injury. It is important to note that none of these conditions exists in isolation. Their effects and impact on injury risk are heavily intertwined and must be considered in the context of prevention activities. Throughout the fact sheets on the social determinants, examples of actions or potential actions that CAPC/CPNP sites have taken to address the social determinants are highlighted. The resource identifies demographic groups and populations that are at higher risk of injury and presents supporting evidence. The purpose of identifying those at higher risk of injury is not to lay blame, but to establish a basis for prioritization of efforts and resources where they are most needed in Canadian society.

Unless otherwise noted, all information is cited in the ACIP report The Social Determinants of Injury that can be found at www.acip.ca.

Social Determinants of Injury Resource Guide | 4 Hosting a Social Determinants of Injury Workshop

Purpose of the Workshop

The Social Determinants of Injury Workshop is an opportunity to gather people together from your community or your organization to learn, reflect and take action on the social determinants of health and injury. Many individuals and organizations may not realize that they are already doing a great deal to address the social determinants of injury. Some examples include literacy promotion, employment supports, parenting support, and overall promotion of child health. The workshop can help to surface and share these initiatives with others in the community and provide opportunities for further collaboration and professional support.

The workshop was designed to help groups and individuals:

 Learn about the link between injury and social and economic conditions  Reflect about the social determinants in their community and what is being done to address them  Decide individually and/or collectively how they may want to move forward in addressing the social determinants of injury

Invitations

You may want to host an event internal to your organization, as staff development or with other CAPC/CPNP’s in your region for strategic planning. Or you may want to broaden the event to other stakeholders in your community. The workshop is designed for a homogenous group or to bring together diverse perspectives and works well with a wide range of participants. If you decide to make this a community event, some suggestions for invitees include:

 Injury prevention professionals  Public health professionals  Women’s organizations  Violence prevention organizations  Municipal, provincial and federal politicians  Youth serving organizations  Housing support or community services organizations  Universities  Literacy programs

Planning the Workshop

It may be helpful to form a small planning committee that can assist with hosting and facilitating the workshop. The following pages contain supportive documents for planning and hosting the workshop including a template program and evaluation.

Social Determinants of Injury Resource Guide | 5 Injuries in Canada: The Facts (Slide 3)

What is an injury?

An injury is defined as the physical damage that occurs when the body is subjected to an acute transfer of energy that exceeds physiological tolerance or from the absence of an essential energy such as heat. These energies are classified as mechanical, thermal, chemical, electrical and radiant.i

Injuries may be classified in two categories:ii

1. Intentional: Injuries that are inflicted intentionally to the self or others. These injuries include suicide, self-harm, and all forms of violence. 2. Unintentional: Injuries that result unintentionally (without intent to harm oneself or others) include injuries from motor vehicle collisions, falls, drowning, and burns.

Despite this difference in classification, it is important to remember that the underlying social and economic determinants of intentional and unintentional injuries are the same.

How do injuries affect Canadians?

 Injury is the leading cause of death and disability between the ages of 1-44 years.iii  Populations and age groups at higher risk for injury include: o Children o Adolescents o Older adults o Aboriginal  Injuries cost Canada approximately $20 billion per year in direct and indirect costs. This includes direct costs to the healthcare system in addition to indirect costs such as lost productivity.iv  Injuries in Canada, 2004v: o 13,667 deaths o 211,768 hospitalized treatment o 3,134,025 non-hospitalized treatment o 62,563 with a permanent partial disability o 5,023 with a permanent total disability  Leading causes of injury death in Canada:vi o Suicide/self-harm o Transport related incidents o Falls  Leading causes of injury hospitalization in Canada:vii o Falls o Other unintentional injuries o Transport related incidents

Social Determinants of Injury Resource Guide | 6 Income and Income Distribution (Slides 4-6)

How does income relate to injury?  Available research and data from around the world demonstrate a strong link between income and rates of injury.  Income inequality can affect injury through: o Negative exposures: Income can affect where you work, live and play and may result in the presence of negative exposures in the physical or social environment. For a child, this may mean living in a neighbourhood Example: Addressing Income Gaps with high traffic speeds and no sidewalks. Many CAPC/CPNP sites helped o Lack of resources held by inform public policy that child safety individuals: Income can determine seats be provided for families with ability to purchase items children under provincial income necessary for safety such as baby assistance policies. gates, booster seats, or bicycle helmets. o Systematic underinvestment in human, physical, health and social infrastructure.  Income is strongly linked to many other social and economic determinants discussed in this resource guide including education and literacy, employment and working conditions, and gender.

What do Canadian statistics tell us?  Although injury rates have been declining across Canada in recent decades, there still remains a significant gap in rates of severe and fatal injuries between the richest and poorest Canadians.  The poorest Canadians experience an injury rate 1.3 times higher than the wealthiest Canadians. If all Canadians had the same injury hospitalization rate as the wealthiest, there would have been 21,000 fewer injury hospitalizations in 2008-2009 alone.  The bar chart on Slide 4 shows the difference in injury hospitalization rates based on neighbourhood income quintile for all types of injury in Canada in one year.  Low income is a predictor of high risk for severe or fatal injury by: o Motor vehicle collision o Falls o Suicide o Violence  Sports and recreation injuries are the one exception to this trend and tend to be higher among middle and high income individuals. These injuries tend to be more minor such as sprains and strains.

Social Determinants of Injury Resource Guide | 7 Income, Injury and Children  Research has demonstrated that children living in low income neighbourhoods, who are on social assistance, or who are Aboriginal experience higher rates of severe and fatal injuries.  As an example, slide 5 shows the annual rates for child and youth injury-related deaths in Nova Scotia based on neighbourhood income quartile. The data shows that children and youth in the lowest income neighbourhoods in that province had an injury fatality rate that was twice as high as children and youth in the highest income neighbourhoods.

Employment and Working Conditions (Slide 7)

What is the state of workplace injury in Canada?  While most injuries in Canada have been on the decline, deaths due to workplace injury have increased.  In 2003, Canada ranked fifth highest among 29 OECD countries in rates of deaths due to workplace injury. Canada was the most highly developed countries among those 5.  Rates of workplace injury vary by province with Ontario experiencing the lowest rates and Atlantic Canada second lowest.  The presence and enforcement of provincial occupational health and safety legislation has been linked to low rates of workplace injury.

Who is at highest risk of workplace injury in Canada?  The most dangerous jobs in Canada include those in the fishing, mining, forestry, agriculture, and construction industries.  30% of Canadians believe that their health and safety are at risk due to their work environment.  There are a variety of social and economic factors such as early childhood experiences, education and socioeconomic status that can affect type of employment or employment opportunities.  Social and economic exclusion in the labour market, particularly for racialized persons and non-European immigrants, can result in under-employment.

Education and Literacy (Slide 8)

How do education and literacy impact risk for Example: Literacy Programming injury? Supporting families to strengthen  Studies demonstrate that rates of serious literacy can have lasting impacts on injuries (fatal and non-fatal) are higher education and employment among those with lower levels of opportunities. education. With less serious injuries, education does not seem to have an impact.

Social Determinants of Injury Resource Guide | 8  The linkage is complex. The effects of education on injury are about more than knowledge of injury risks.  Levels of education and literacy intersect with early childhood experiences, socioeconomic status, employment, and access to services. Early childhood material or social deprivation can have a lifelong impact on learning and development.  Stable, safe, and supportive environments that are bolstered by public and private sector policies and programs are crucial to optimal healthy child development and reduced risk of injury.

Housing and Injury (Slide 9)

How does housing relate to injury?

 Quality, safety, and location of housing Example: Home Safety Programming are related to income.  Older units, rental housing, and low CAPC/CPNP programs are a valuable income housing have all been associated resource for parents and guardians to with higher rates of injury, especially among learn about home safety issues such children. Areas of concentrated poverty as burns and falls. They may also at also influence injury risk among children. times be a source of safety  Residential hazards include: equipment to improve child safety in o Structural defects the home (e.g. baby gates). o Insufficient lighting o Lack of window guards, grab bars or safety gates o Substandard heating and electrical systems o Stairways without appropriate safety features  Poorly maintained or unaffordable housing options are associated with higher stress, mental health issues and substance abuse.  Injuries resulting from structural problems are often more serious than those that result from common household hazards (e.g. falls from furniture).  Children and older adults are especially vulnerable to injuries in the home.

Gender (Slide 10)

What is the difference between sex and gender?  Sex refers to the biological and anatomical differences between males and females.  Gender refers to socially constructed roles, attitudes, and behaviours that are assigned to men and women in a particular culture. Many of these socially constructed factors create differences in injury risk.  Much of the research in this section is presented in dichotomous terms of “male” and “female”. This may not adequately encompass the experiences of all individuals when describing their sex or gender identity.

How does gender affect risk for injury?

Social Determinants of Injury Resource Guide | 9  Unequal power relationships based on gender affect opportunities for income and employment, both of which are strongly linked to injury risk. Canadian women are paid an average of $17,000 less per year than their male counterparts. Women are more likely to be living in low income situations than men.  Canadian men and boys are more likely than women and girls to be injured. Social constructs of masculinity that emphasize risk-taking, aggressiveness and dominance can lead to higher risk for injury. Males are also socialized to be self-reliant and avoid help-seeking behaviours.  Hypersexualization (the commodification or exploitation of sexuality) of women and girls in industries such as fashion, media, toys, alcohol, and popular culture have numerous consequences for females in North America. Impacts on physical and mental health, cognitive functioning, sexuality, and risk-taking have been reported. Sexual harassment and violence towards females has been associated with this growing phenomenon, which intersects with constructs of masculinity to perpetuate gender inequity and power imbalances.  Gender also intersects with social exclusion. Canadian men living in low income areas have the lowest life expectancy of all Canadians and are linked with increased risk of death by suicide, homelessness, substance abuse, or involvement in violent crime as either a victim or perpetrator.

Rural and Urban Environments (Slide 11)

How does the urban or rural setting relate to injury?  Urban and rural settings each have different risk factors for injury.  Urban settings: o Urbanization often results in polarization of rich and poor, with areas of concentrated poverty exacerbating injury risk. o Urban poor have less access to informal resources (gardens, wood for heating) which can increase stress.  Rural settings: o Access to emergency care is not as readily available in rural settings. Delays in trauma care can result in worsened injury outcomes. o Some provincial comparisons between rural and urban settings (e.g. Manitoba) have found that children in rural settings were more likely to experience severe injuries and death than children in urban settings. o Motor vehicle collisions in rural areas are strongly correlated with socio-economic status. Longer driver distances, reliance on less road-worthy vehicles and poor road conditions are all factors.

Age, Population, and Injury

Social Determinants of Injury Resource Guide | 10 Social and economic conditions may affect certain populations or age groups at higher risk for injury. The purpose of identifying those at high risk of injury is not to lay blame, but to establish a basis for prioritization of injury prevention efforts and resources where they are most needed.

Children Aged 1-14 (Slide 12)

What do we know about injuries to children in Canada?  Injuries are the leading cause of death and disability to children in Canada. Injuries are responsible for more deaths to children than all other causes combined.  Although leading causes of death vary by province in region, nationally the leading causes are motor vehicle collisions, suffocation, drowning, and burns. Falls are the leading cause of hospitalization.  While most types of injuries to children have been declining in recent years, rates of death by suicide are actually increasing. Suicide is the second leading cause of injury- related death to children in Canada. In addition, rates of death due to assault were unchanged.  As with most other age groups, male children experienced higher rates of injury than female children.  Canada does not perform well in comparison to other developed counties. Canada ranks 22nd out of 29 member countries of the Organization for Economic Cooperation and Development (OECD) in preventing childhood injuries.

How does socioeconomic status affect children’s risk for injury?  There is a strong effect of income on children’s injuries. Children who live in families who are on social assistance have higher rates of injury than children not on social assistance. Children who are Aboriginal also had higher rates of injury. For Aboriginal children and children on social assistance, the difference in injury rate was particularly strong for burns and poisonings.  Refer back to Slide 5, which demonstrates the difference between child injury fatalities by income in Nova Scotia. Similar findings have been found in other provinces.  Socioeconomic status affects child injury in numerous ways. o Housing quality and overcrowding. o Early material and social deprivation can negatively impact development and learning. o Low income neighbourhoods may have more hazards, such as high speed traffic, poor lighting, and other hazardous conditions. o Families may not be able to access safety resources and equipment.  The relationship between socioeconomic status and minor injuries is less clear. Minor injuries, such as strains and sprains, typically do not show an effect of income. This may be due in part due to opportunities for sports and recreation that children in middle-high income brackets have.

Adolescents (Slides 13-14)

Social Determinants of Injury Resource Guide | 11 Why are adolescents at higher risk for injury?

 Much has been learned in recent years about brain development in adolescence and how it relates to risk taking behaviours. Our brains continue to develop until our early 20’s at which time the effect on risk-taking is reduced.  It is important to note that some risk taking is healthy for development. What we want to avoid are those risks that could have serious negative consequences.  Although adolescents have cognitive abilities similar to adults, they may weigh the positive and negative consequences of risk-taking differently. The benefits (e.g. social) of taking a risk may seem to outweigh the possible consequences. In short, it’s not that adolescents are unaware of negative consequences, but that they may be perceived differently than an adult would perceive them.  Frontal lobe development has an impact via propensity for impulsivity and a more active stress response, which can affect decision-making.

How are alcohol and cannabis related to adolescent risk taking?

 Use of alcohol and cannabis, both illegal for this age group, is a risk-taking behavior in itself with numerous consequences. Furthermore, use of these and other substances place all individuals at higher risk for injury.  Alcohol is still the most common drug used by adolescents. It is important to note that Canada and certain regions in particular are experiencing a declining age of first drink and heavier drinking patterns among youth. The implications for injury, healthy development, and other health issues are vast.  Adolescents are particularly susceptible to alcohol industry marketing, advertising and promotions along with cheap prices for high alcohol content drinks.

What do we know about adolescents, socioeconomic status, and injury?

 Like other age groups, rates of injury among adolescents are affected by income for most injury issues.  One injury issue where the picture is less clear is motor vehicle related injury hospitalizations. On slide 13, you will see injury hospitalizations rates for income for all age groups. While most age groups follow a predictable pattern of effect of income, the adolescent age group is less predictable. While there is still a protective effective of income with the highest income youth, the lower income brackets do not display a predictable pattern of injury declining with wealth.

What are the implications for injury prevention with adolescents?

 With knowledge that brain development is a primary reason why adolescents are at higher risk for injury, injury prevention practitioners can make the case for safe environments as an injury prevention approach rather than education-only initiatives.  As an example, research has demonstrated that driver education courses do not reduce risk of motor vehicle collisions among adolescents. What does work is the ability to gain experience. As a result, graduated drivers’ licensing (GDL) policies have been

Social Determinants of Injury Resource Guide | 12 implemented widely across Canada with positive results. GDL allows for youth to gain experience driving under the safest possible conditions (e.g. during daytime, with few additional passengers, zero blood alcohol content, etc).

Seniors (Slide 15)

How does socio-economic status affect seniors in Canada?  Falls are the most common form of injury for Canadians over the age of 50. Older women are far more likely to be injured by a fall than older men.  As demonstrated in the bar graph on Slide 14, income plays a strong role in risk for hospitalization due to a fall. Seniors in the lowest income bracket have the highest rate of hospitalization due to a fall. With every increase in income, the rate of hospitalization shows a significant decline.  Low income can contribute to falls due to the quality of the physical environment in the home or neighbourhood, nutrition, access to safety features and equipment, stress, and lack of social support.  Low income seniors may also be at higher risk for burns from fire in the home.

Aboriginal Communities (Slides 16-17)

What are the injury issues in Aboriginal communities?  Aboriginal communities have rates of injury that are much higher than the non-Aboriginal population in Canada. For all types of injuries, the rate is 3.5 times the national average. When specific injury issues are separated out, the disparity is even greater. Suicide in Aboriginal communities is estimated to be 7 times higher than in non-Aboriginal communities.  Motor vehicle collisions are the leading cause of injury related death in Aboriginal communities. Lack of seatbelt use is cited as a common factor. Collisions occur both on road and with off road vehicles such as ATVs and snowmobiles. Remoteness of many communities affects road quality and the length of distance traveled as well as emergency response time.  Other common causes of injury-related death in Aboriginal communities include drowning, burns from fire, suicide, overdose, and violence.

What are the social and economic conditions that lead to higher injury rates?  There are a number of social and economic factors that combine to affect rates of intentional and unintentional injury in Aboriginal communities in Canada. Higher rates of poverty and social exclusion, poorer quality housing and housing shortages, lower levels of education and employment, and a young population all contribute to increased injuries.  In addition to the social determinants listed above, a number of different determinants specific to Aboriginal people have been identified. These additional determinants incorporate the historical experiences and culture of Aboriginal people in Canada and

Social Determinants of Injury Resource Guide | 13 include the effects of colonization, globalization, and migration as well as the need for cultural continuity, access, territory and self-determination.  Research has shown that policies that address these additional determinants can contribute to decreased rates of suicide in Aboriginal communities. Communities that have self-governance, education, health and emergency services, cultural facilities, and land claims resolution have been shown to have lower rates of suicide when compared to communities that do not have these conditions. A minimum of three of these factors has been shown to have a protective effect.

LGBT Community (Slide 18)

How is the Lesbian, Gay, Bisexual and Transgender (LGBT) community at higher risk of injury?  Many members of the LGBT community may experience homophobia, transphobia, or biphobia. This may take the form of harassment, discrimination, social exclusion, or violence. These experiences affect overall health and well-being for LGBT people and can lead to increased issues with mental health and substance use.  While there is little data on whether rates of unintentional injury are higher among the LGBT population, research has demonstrated that rates of violence and threats of violence are higher. In addition, suicidal ideation and self-harm tend to be higher.  Suicide attempts among LGBT youth have been shown to be lower in supportive social environments. This research speaks to the importance of social policies outside of the healthcare system as contributors to good health and safety. In this particular study, political rhetoric supportive of the LGBT community, the presence and enforcement of anti-bullying and anti-discrimination policies, the presence of gay-straight alliances, and the proportion of same-sex couples in the community all contributed to a lower rate of suicide attempts among LGBT youth. Communities that did not have a supportive social environment as measured by these above listed factors had higher rates of suicide attempts among LGBT youth.

Best Practice Considerations (Slide 19)

How do we prevent injuries in the context of the social determinants?

 Reducing injuries is a complex process that must take into account the multilevel factors that influence behavior, environments, and outcomes.  The complicated, multilevel dynamic of injury means that a comprehensive, coordinated approach is required for effective injury prevention strategies.  Excessive focus on either micro or macro level influences is likely to result in ineffective strategies.  As indicated in the chart on slide 18, it is important to incorporate a range of interventions recognizing that a comprehensive strategy that addresses the social determinants of injury will have the most effect.

What do we know about preventing injuries?

Social Determinants of Injury Resource Guide | 14  Injuries are preventable. The injury prevention community has traditionally focused on the “3 E’s” Model of using Education, Enforcement, and Engineering strategies for injury prevention. While these strategies are important, the complex and dynamic nature of injuries and human behavior may require a more integrated and comprehensive approach.viii  A health promotion approach integrates the need for both environmental and behavioural change while acknowledging the importance of social and economic conditions as root causes for injury risk. Health promotion action includes building healthy public policy, creating supportive environments, strengthening community actions, developing personal skills, and reorienting health services. We can apply the health promotion approach to the 3 E’s and interpret them more broadly. Education may be a simplification of an individual level initiatives such as developing personal skills. The term enforcement can be expanded to include healthy public policy at various levels and the role of injury prevention professionals in promoting healthy public policy. Engineering and design are integral to creating safe, supportive, physical environments and ensuring access the appropriate services.

Primordial Prevention (Slide 20)

What is primordial prevention?

 Primordial prevention involves preventing the “emergence and establishment of environmental, economic, social and behavioural conditions, cultural patterns of living and so on that are known to increase the risk of disease” or injury.ix  Essentially, primordial prevention means addressing the social determinants of injury or improving daily living conditions so that environments are safer and people are supported. What are the implications for injury prevention?

 Many efforts to prevent injury take place at the level of primary prevention. It is important for injury prevention practitioners to see their role in promoting policies and initiatives that support primordial prevention.  Based on the evidence in this resource and in The Social Determinants of Injury Report addressing injuries from the perspective of primordial prevention would result in a decrease in injuries. Furthermore, it would help to ensure that people are more receptive to other forms of prevention, such as injury prevention messaging and policies.

Strong Social Policy (Slide 21)

What is social policy and why is it important?

 Social policy encompasses a range of benefits, programs, and supports that protect citizens through various life changes that can affect their health. These policies function as a social safety net to ensure that people are not negatively impacted by these life changes whether they are positive or negative changes.  Examples of social policies include family allowances, childcare, employment insurance, Social Determinants of Injury Resource Guide | 15 health and social services, social assistance, disability benefits, home care, and retirement pensions.

What do we know about social policies in Canada?  Like other developed nations, Canada has a range of social policies for its citizens including, but not limited to, universal healthcare, employment insurance, and disability benefits.  Despite the presence of these policies, it is important to note that compared to other developed nations in the OECD, Canada ranks low in spending on these benefits. Among the OECD nations, Canada is among the lowest public spenders on early childhood education and care, seniors’ benefits and supports, social assistance payments, unemployment benefits, benefits and services for people with disabilities, and supports and benefits to families with children.  In recent years, spending on social policies and the ability for Canadians to qualify for these benefits has eroded.

What are the implications for injury prevention?  Low spending on social policies means that Canadians who are at the highest risk for injury may not be receiving the resources they need to live safe and healthy lives.  Adequate public spending on social policies would reduce injuries and other health issues in Canada.

Social Determinants of Injury Resource Guide | 16 Social Determinants of Injury Sample Workshop Agenda for Participants

Welcome and Framing (15 minutes)  What does today look like? o Learn – Social Determinants of Injury o Reflect – What does it mean in our work? o Action – What can we do?

Check-In (15 minutes)  Why did you come today?  In small groups – 5-8 per group (or one group if numbers are small)

Presentation of Report The Social Determinants of Injury (45 minutes)

Reflection (15 minutes)  How did this make you feel?  In small groups – 5-8 per group (or one group if numbers are small)

World Café: What can we do about this? (1 hour)  Round #1: What are you already doing?  Round #2: What more could you be doing?  Round #3: How do you want to move forward?

Capture high level outcomes (15 minutes)  Each table host brings forward issues

Next Steps (15 minutes)  Evaluation  One word checkout

Social Determinants of Injury Resource Guide | 17 The Social Determinants of Injury Workshop Facilitator’s Guide

The following is intended to accompany the template workshop program on the previous page and will provide details on the techniques and the materials needed. As time to host workshops will vary along with the needs of your group, the agenda is designed to be flexible to accommodate different circumstances and adapt to the needs of stakeholders. The program was designed using principles from the Art of Hosting Strategic Conversations. The following descriptions of the activities have been adapted from the Art of Hosting website.x

Welcome and Framing

 The Facilitator or Host welcomes the participants to the workshop and reviews the three key components of the day – Learn, Reflect, Act.  Participants will learn about how social and economic conditions relate to risk for injuries. They will then have the opportunity to reflect on this information and work together to decide how they may want to take action.

Check-In

 The check-in is an opportunity for participants to get to know one another and to collectively commit to the gathering. It helps to ensure that people are truly present and ready to work through the task at hand.  If you have time, check-in can be done as a large group sitting in a circle. If you are short on time or have too many participants, check-in can be done in small groups.  Check-in can start with a volunteer and then pass around the circle. If a participant is not ready, they may pass their turn and respond later. Often a talking piece is used so that only one person is speaking at a time.  A powerful question is central to the check-in. In the Social Determinants Workshop, we chose the question “what brought you here today?” to unearth the interests and motivations in the room for addressing the social determinants of injury.  If you would like to record the check-in, you can put large sticky notes or flip chart paper on the tables for people to write down their responses. Or you may choose to have some participants do a report back to the larger group if they are at small tables.

The World Caféxi

 The Principles of World Café o Create hospitable space o Ask questions that matter o Connect diverse perspectives o Encourage each participant’s contribution o Listen together for patterns, insights, and deeper questions o Share collective discoveries  Step 1: Create a Café Atmosphere Social Determinants of Injury Resource Guide | 18 o The World Café is about creating conversations around questions that matter. Like a real café, the World Café can be used to bring people together in a comfortable setting to share ideas and create possibilities for action. o To facilitate the World Café, set the workshop space up with small round tables for 5-6 people. Create a café atmosphere with tablecloths and flowers.

 Step 2: Introduce the World Café o Provide participants with an overview of the purpose and principles of World Café. o Describe the logistics of how the café operates.

 Step 3: Small Group Rounds o The World Café involves typically a minimum of three 20 minute rounds where participants are seated at the café tables. Each table has a host that will remain at the same table throughout the hour long activity. The other participants switch to a new table at the end of each round. This allows for a good mix of ideas and discussion. o Role of the host: The host remains at the same table throughout the three rounds. The host records the conversation on flip chart paper on the table and is responsible for bringing the history of previous conversations to new participants who join the table. o Each of the 20 minute rounds involves a question. During Round 1 everyone is discussing Question 1, Round 2 is Question 2 and so on. The three questions provided in the sample agenda for the Social Determinants of Injury are designed to help workshop attendees celebrate what is already being done and plan for moving forward. o Ensure that each table has flip chart paper on the table top along with plenty of markers. Encourage all participants to play, doodle and draw throughout the activity.

Check-Out

 The purpose of the check-out is to give an official close to the meeting and allow participants to reflect on the gathering.  The host may allow for open reflection or, as in the Social Determinants Workshop Agenda, request a one word check-out. This is often done “popcorn style” where participants can “pop if they’re hot” by calling out their word when they’re ready.

Capturing the Outcomes of the Workshop: The Harvest

 Throughout the workshop you may want to employ a number of ways for capturing the conversations and activities of participants.  Provide plenty of flip chart paper, markers, and sticky notes for recording discussions, reflections, and feedback.

Social Determinants of Injury Resource Guide | 19 Social Determinants of Injury Workshop Evaluation Form

Please indicate your agreement with the following statements:

Today’s session was applicable to me and my work.

Strongly Disagree 1 2 3 4 5 Strongly Agree

Today’s session addressed topics that are relevant and important to me.

Today’s session encouraged me to incorporate (or increase incorporation) of the social determinants into my work.

I am leaving today’s session feeling that I have a way to move forward with the work. Strongly Disagree 1 2 3 4 5 Strongly Agree

How do you plan to incorporate what you learned today into your own practice?

In the short term: ______

______

In the long term: ______

______

How could today’s session have been improved?

______

Social Determinants of Injury Resource Guide | 20 Thank you!

Social Determinants of Injury Resource Guide | 21 i Province of Nova Scotia. (2009). Nova Scotia’s Renewed Injury Prevention Strategy: Taking it to the Next Level. Halifax, NS: Author. ii Ibid. iii Statistics Canada. (2002). Death by cause, Canada. External causes of morbidity and mortality, age group and sex. Ottawa: Government of Canada. iv SMARTRISK. (2009). The economic burden of injury in Canada. Retrieved March 5, 2012 from http://www.smartrisk.ca/downloads/burden/Canada2009/EBI-Eng-Final.pdf v SMARTRISK. (2009). The economic burden of injury in Canada. Retrieved March 5, 2012 from http://www.smartrisk.ca/downloads/burden/Canada2009/EBI-Eng-Final.pdf vi Ibid. vii Ibid. viii Gielen, A. and Sleet, D. (2003). Application of behavior change theories and methods to injury prevention. Epidemiologic Reviews, 25, 65-76. ix Ursoniu, S. (2009). Primordial prevention, developing countries and the epidemiologic transition: Thirty years later. Wiener kinische Wochenschrift, 121, 168-72. x Art of Hosting. (n.d.). Welcome to the Art of Hosting. Retrieved March 5, 2012 from www.artofhosting.org xi The World Café. (n.d.). The World Café Method. Retrieved March 5, 2012 from http://www.theworldcafe.com/method.html