Evaluation of the Injury Prevention Program 1992-1996 Author(S) Type of Report & Period Covered: Day L, Ozanne-Smith J, Cassell E.& Mcgrath A

LATROBE VALLEY BETTER HEALTH PROJECT

EVALUATION OF THE INJURY PREVENTION PROGRAM

1992-1996

by Lesley M. Day Joan Ozanne-Smith Erin Cassell Alicia McGrath

July, 1997

Report No. 114 11 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE REPORT DOCUMENTATION PAGE Report No. Date ISBN Pages 114 July 1997 0 7326 0694 2 111 Title and sub-title: Latrobe Valley Better Health Project: Evaluation of the Injury Prevention Program 1992-1996 Author(s) Type of Report & Period Covered: Day L, Ozanne-Smith J, Cassell E.& McGrath A. General, 1992-1996 Sponsoring Organisation(s): Victorian Health Promotion Foundation Public Health Research and Development Committee, NHMRC Abstract: Evidence for the effectiveness of the community based approach to "all age all injury prevention" applied in the Australian context is limited. This study's aim was to evaluate the Latrobe Valley Better Health Injury Prevention Program, a community based intervention in south-east Victoria, Australia. The evaluation design was quasi-experimental including pre- and post-intervention observations in a population of approximately 75,000. There was no single comparison community, rather comparative data was used where possible. Process measures included key informant interviews with local organisation representatives. Impact evaluation relied mainly on self-reported changes in injury risk and protective factors, gathered by a random telephone survey. Outcome evaluation was based on five years of emergency department injury surveillance data for the Latrobe Valley. Modelling of injury rate data was performed using both Poisson and logistic regression. The program built strategic partnerships, increasing the emphasis on safety at the local level. Promotional and educational activities were implemented in the targeted areas of home, sport, and playground injuries, and alcohol misuse among the youth. Some 51,000 educational contacts were made with the community and 7470 resource items distributed. There was a 7.3% increase in the proportion of households purchasing home safety items (p=0.55). Unsafe equipment was replaced and undersurfacing upgraded in municipal playgrounds. The demand for and availability of protective equipment for sport increased. The age standardised rate per 100,000 persons for emergency department presentations for all targeted injury fell from 6594 in the first program year to 4821 in 1995/96 (p=0.017). There were significant decreases in the presentation rates for home injuries among all age groups except for those 65 years and over, playground injuries among 5-14, 15-24 and 25-64 year olds, and sport injury among 15-24 year olds only. The direct program cost per injury prevented was $272. There were no decreases in alcohol purchases by liquor outlets, and the rate of arrest for being drunk and disorderly increased among 10-24 year olds. However, significant reductions were observed for assaults among 10-24 year olds compared to those over 25 years. Most program objectives were met to some extent. The lack of a comparison community and injury data limits the conclusions which can be drawn about the association between the program and the injury reductions observed. However, the reductions were associated to some extent with changes in injury risk and protective factors and were greatest for the injury issues subjected to the most intense activity. There is merit in monitoring the impact of the ongoing injury prevention program, only with improvements to the evaluation design including a comparison community.

Key Words: (IRRD except when marked*) Disclaimer evaluation, injury prevention, community-based This report is disseminated in the interest of infonnation exchange. The views expressed here are those of the authors, and not necessarily those ofMonash University Reproduction of this page is authorised Monash University Accident Research Centre, WellingtonRoad, Clayton, Victoria, 3168, Australia. Telephone: +61 399054371, Fax: +61 3 99054363

LATROBE VALLEY BETTER HEALTH PROJECT III IV MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Contents

EXECUTIVE SUMMARy Xl

1. INTRODUCTION 1

2. PROG RAM STRUCTURE 3 2.1 AIMS AND OBJECTIVES 3

2.2 COMMITTEES AND WORKING GROUPS 3 2.3 IMPLEMENTATION 4

3. EVALUAliON METHODS 5 3.1 EVALUATION DESIGN 5 3.2 PROCESS EVALUATION 5 3.3 IMPACT EVALUATION 6 3.3.1 Telephone survey 6 3.3.2 Other methods 7 3.4 OUTCOME EVALUATION 7 3.4.1 Definition of program region 7 3.4.2 Self reported injury 7 3.4.3 Emergency department injury presentations 8 3.4.4 Injury hospitalisations : 10 3.4.5 Motor vehicle crash data 11 3.4.6 Drunk and disorderly arrests 12 3.5 STATISTICAL ANALYSES 12 3.6 COSTS PER INJURY PREVENTED 14

4. RESULTS 15 4.1 GENERAL 15 4.2 HOME INJURY PREVENTION 15 4.2.1 Aims and objectives 15 4.2.2 Process measures 16 4.2.3 Impact measures 20 4.2.4 Outcome measures 21 4.3 PLAYGROUND INJURY PREVENTION 21 4.3.1 Aims and objectives 21 4.3.2 Process measures 22 4.3.3 Impact measures 22 4.3.4 Outcome measures 23 4.4 SPORTS INJURY PREVENTION 24 4.4.1 Aims and objectives 24 4.4.2 Process measures : 25 4.4.3 Impact measures 26 4.4.4 Outcome measures ; 26

LATROBE VALLEY BEITER HEALTH PROJECT v 4.5 ALCOHOL MISUSE 27 4.5.1 Aim and objectives 28 4.5.2 Process measures 28 4.5.3 Impact measures '" 30 4.6 STRATEGIC LINKS WITH LOCAL ORGANISATIONS 32 4.7 INJURY OUTCOME '" 33 4.7.1 Self reported injury (telephone survey) 33 4.7.2 Emergency department presentations 33 4.8 COST BENEFIT ESTIMATES 34 4.9 INSTITUTIONALISATION AND SUSTAINABILITY 34 4.9.1 Design and permanent environmental changes 35 4.9.2 Policy and legislative changes 35 4.9.3 Institutionalisation 35

5. DISCUSSION AND RECOMMENDATIONS 39 5.1 EVALUATION DESIGN AND METHODS 39 5.2 ATI AINMENT OF PROGRAM OBJECTIVES 40 5.3 INJURY REDUCTIONS 41 5.4 COST EFFECTIVENESS OF COMMUNITY BASED INJURY PREVENTION 42 5.5 PROGRAM SUSTAINABILITY 43 5.6 FUTURE DIRECTIONS '" 43 5.6.2 Continuing evaluation of the Latrobe Valley Better Health Injury Prevention Program 44 5.6.3 Future directions for community-based injury prevention program evaluation 44

APPENDIX 1 PRE AND POST INTERVENTION SURVEYS 47

APPENDIX 2 COMPARISON OF PRE AND POST INTERVENTION SURVEY SAM PLES 57

APPENDIX 3 STATISTICAL LOCAL AREAS FOR LA TROBE VALLEY PROGRAM REGION AND COMPARISON OF SMALL RURAL CENTRE AREAS 61

APPENDIX 4 EMERGENCY DEPARTMENT PRESENTATIONS: POISSON REG RESS ION ANALYSIS ...•...... •..•...... •...... •....•••...... •.••.•...... •..•• 63

APPENDIX 5 EMERGENCY DEPARTMENT PRESENTATIONS: LOGISTIC REG RESS ION ANALYSIS ...... •..•...... ••...... •...... •....•••..•...... •.. 65

APPENDIX 6 INJURY FREQUENCIES AND RATES ...... •...... •...... •...... •...... ••... 73

APPENDIX 7 STRATEGIC LINKS WITH LOCAL ORGANiSATIONS ...... •.•...... •.•. 79

APPENDIX 8 MATCHING OF PROGRAM OBJECTIVES WITH ACHIEVEMENTS MEAS URE D ••.•.•....•.•...... ••....•...... ••....•...... ••....••...•...•...•...... •..••..••....•...... •...•...... •..•.• 85

RE F E RENC ES 91

VI MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Figures

FIGURE 1 AGE STANDARDISED UNINTENTIONAL HOME INJURY EMERGENCY DEPARTMENT PRESENTATIONS (INCLUDING THOSE ADMITTED), LRH 1991/92-1995/96. OTHER UNINTENTIONAL EXCLUDES PROGRAM TARGETED INJURY, ROAD AND WORK RELATED INJURIES ....•..•.•.•.•.••.•.•...•..•..•.•.•..•.•.••.•.•.••. 21 FIGURE 2 AGE STANDARDISED UNINTENTIONAL PLAYGROUND AND PLAYGROUND EQUIPMENT INJURIES, EMERGENCY DEPARTMENT PRESENTATIONS (INCLUDING THOSE ADMITTED), LRH 1991/92• 1995/96. OTHER UNINTENTIONAL EXCLUDES PROGRAM TARGETED INJURY, ROAD AND WORK RELATED INJURIES •...•...... •.•....•....•.....•...•...... •.....••...... •...... •.••.•.••..•.•...•...•....•..•..•.....• 24 FIGURE 3 AGE STANDARDISED UNINTENTIONAL SPORTS INJURY, EMERGENCY DEPARTMENT PRESENTATIONS (INCLUDING THOSE ADMITTED), LRH 1991/92-1995/96. OTHER UNINTENTIONAL EXCLUDES PROGRAM TARGETED INJURY, ROAD AND WORK RELATED INJURIES ••..•.•.•.••..•.•..•...... •..•....•.•.••..••..•.•.. 27 FIGURE 4 DRUNK AND DISORDERLY ARREST RATES, LATROBE V ALLEY BETTER HEALTH INJURY PREVENTION PROGRAM REGION, 1991/92-1995/96 31 FIGURE 5 HIGH ALCOHOL TIME SERIOUS MOTOR VEmCLE CRASH CRUDE AGE SPECIFIC RATES FOR 0-24 YEAR AGE GROUP, LATROBE V ALLEY PROGRAM REGION AND VICTORIAN SMALL RURAL CENTRES (COMPARISON REGION), 1987/88-1995/96 32 FIGURE 6 INTENTIONAL INJURY INFLICTED BY OTHERS, EMERGENCY DEPARTMENT PRESENTATIONS (INCLUDING THOSE ADMITTED), LRH 1991/92-1995/96 32 FIGURE 7 AGE STANDARDISED UNINTENTIONAL EMERGENCY DEPARTMENT PRESENTATIONS (INCLUDING THOSE ADMfITED), LRH 1991/92-1995/96. ALL TARGETED INJURY INCLUDES HOME, PLAYGROUND AND SPORT INJURY. OTHER EXCLUDES PROGRAM TARGETED INJURY, ROAD AND WORK RELATED INJURIES ..••..•..•.••..•.••....•....•....•...••...•... ,...•••...•...... •.•...•••.....•..•.•..•...•..•.•.•..••. .34

Tables

TABLE 1: EVALUATION PHASES, LATROBEVALLEYBETTERHEALTHINJURYPREVENTIONPROGRAM, 1992- 1996 5 TABLE 2: TELEPHONE SURVEYS, LATROBE VALLEY BETTER HEALTH PROJECT EVALUATION, VICTORIA ••.••.••.•.•.•. 7 TABLE 3: LATROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM REGION, VICTORIA, 1992-1996 ..... 8 TABLE 4: DATA SOURCES FOR THE INJURY OUTCOME ANALYSES, LATROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM, VICTORIA, 1992-1996 8 TABLE 5: CAPTURE RATES (%), VICTORIAN INJURY SURVEILLANCE SYSTEM, LATROBE REGIONAL HOSPITAL, 1991/92-1995/96 , 9 TABLE 6: SELECTION CRITERIA FOR INJURY DATA EXTRACTION, VICTORIAN INJURY SURVEILLANCE SYSTEM, LATROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM, VICTORIA, 1992-1996 10 TABLE 7: SUMMARY OF THE RURAL, REMOTE AND METROPOLITAN AREAS CLASSIFICATION SYSTEM STRUCTURE •••.•.•.•••..•..••...•.•.•••....•.••.•..••...... ••....•...... •.•.•.•••...•••...•.••...•.•...••.••.•.•.•...•.•.•.•.•....••..•.••.••.••.•.• 11 TABLE 8: HOME SAFETY EDUCATION SESSIONS FOR COMMUNITY MEMBERS, LA TROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM, 1992-1996 17 TABLE 9: HOME SAFETY EDUCATION SESSIONS FOR PROFESSIONALS, LATROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM, 1992-1996 18 TABLE 10: MOBILE SAFETY DISPLAY, LA TROBE V ALLEY BETTER HEALTH INJURY PREVENTION PROGRAM, 1992-1996 19 TABLE 11: HOME INJURY PREVENTION RESOURCE MATERIAL DISTRIBUTED, LATROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM, 1992-1996 20 TABLE 12: PLAYGROUND INJURY PREVENTION RESOURCE MATERIAL DISTRIBUTED, LA TROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM, 1992-1996 23 TABLE 13: SPORTS INJURY PREVENTION DISPLAYS, LATROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM 1992-1996 25 TABLE 14: PERCENTAGE CHANGE IN ALCOHOL SALES (UTRES) LA TROBE SmRE AND COUNTRY VICTORIA 1991-1995 30 TABLE 15: PoISSON REGRESSION ANALYSIS, DRUNK AND DISORDERLY ARREST RATES, LATROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM REGION, 1991/92-1995/96 .31 TABLE 16: POISSON REGRESSION ANALYSIS, mGH ALCOHOL TIME SERIOUS MOTOR VEmCLE CRASH CRUDE RATES 0-24 YEARS, LATROBE VALLEY BETTER HEALTH INJURY PREVENTION PROGRAM REGION AND VICTORIAN SMALL RURAL CENTRES, 1987/88-1995/96 .31

LATROBE VALLEY BEITER HEALTH PROJECT vii viii MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE ACKNOWLEDGMENTS

The Monash University Accident Research Centre gratefully acknowledges the co-operation of the Latrobe Valley Better Health Project Management and Injury Reference Committees, chaired by Mr John Guy and Dr Glynn Derwent-Smith, during the course of this evaluation. Further, we have been particularly fortunate to have had a trusting and open working relationship with the injury prevention program officer, Mr Henk Harberts. We are grateful to Henk for his time, for making project records available and for facilitating important links with the Latrobe Valley community.

Our colleagues, especially Dr David Harvey, fonnerly of the Monash University Gippsland Centre for Research in Health Education and Social Sciences collaborated on the pre and post• intervention telephone surveys and on other aspects of the evaluation.

Various members and organisations of the Latrobe Valley community were helpful in providing infonnation pertinent to the evaluation. In this regard we are indebted to John Nicholl, Frank Doonan, Brian McKenzie, Brian Quigley, Lorraine Bartling, Fred Boram and Lesley Hammond.

A considerable amount of data was required for the evaluation of the injury prevention program. The inclusion of injury outcome data would not have been possible without the operation of the Victorian Injury Surveillance System (VISS) at the Latrobe Regional Hospital. The cooperation and enthusiasm of Dr Glynn Derwent-Smith, Julia Palmer, and the Latrobe Regional Hospital emergency department and medical records staff is gratefully acknowledged.

Under the guidance of Sergeant Rod Connelly, the local police reliably collected drunk and disorderly arrest data on a monthly basis for several years. The Victorian Department of Human Services, Liquor Licensing Commission, and VicRoads also provided data which fonned the basis of the evaluation.

At the Monash University Accident Research Centre, a team of people assisted with this project, and the authors remain indebted to the staff for their respective contributions. Professor Peter Vulcan provided enthusiastic support throughout the evaluation period, and made critical comment on this report. Graeme Watt conducted the comparative analysis of the pre and post-intervention surveys. Stuart Newstead and David Dyte devised the analytic techniques for the comparative analysis of trends in injury rates. Sue Conwell, John Lim, Christina Leong assisted with data coding and entry for the telephone surveys. VISS staff, Viriginia Routley, Karen Ashby and Christine Chestennan assisted with emergency department injury data coding, entry, analysis and extraction. Anita Imberger, Julie Valuri and Voula Stathakis conducted other data analyses. Wendy Watson provided advice on the cost of Injury,

Finally, we acknowledge the Victorian Health Promotion Foundation and the National Health and Medical Research Council for funding this project over a number of years. Ms Trish Mundy, of the Victorian Health Promotion Foundation, has been particularly helpful in facilitating the longevity of this project.

LATROBE VALLEY BETTER HEALTH PROJECT ix X MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE EXECUTIVE SUMMARY

Introduction The application of the community based approach to "all age all injury prevention" has been applied increasingly in various parts of the world, following the first successful reports in Sweden during the early 1980's. Controlled evaluations of these programs have identified varying degrees of success with respect to the intended health outcome ie., frequency and severity of injury. Significant decreases in injury relative to comparison communities have been reported in Sweden and Norway. In Australia, the only controlled evaluation of an all age all injury prevention program demonstrated a significant effect on self reported injury only, compared with the comparison community after six years. This document reports on the evaluation of the first four years of the Latrobe Valley Better Health (LVBH) Injury Prevention Program, a community based program, modelled on the Swedish experience, in the Latrobe Valley, Victoria.

Methods The aim of the LVBH Injury Prevention Program was to utilise a community intervention approach to prevent injuries, reduce hazards and increase public awareness of measures to reduce the incidence and severity of injuries in the Latrobe Valley community (population 75,500 - 76,560). The program focussed on four main areas of activity: home, sports and playground injury prevention, and alcohol misuse among the youth.

The evaluation is a quasi-experimental uncontrolled design which includes pre and post intervention observations. There is no single comparison community in which a range of equivalent measures have been recorded due to budgetary constraints. However, where possible, comparative data from a range of sources has been included. The current evaluation covers the period from May 1992 to June 1996. The following recognised phases of evaluation are included: process, impact and outcome.

Data for process evaluation was obtained from program reports, the program officer's diaries and media file, and through interviews and discussions with key individuals from other local organisations.

The major method utilised for the impact evaluation was random household telephone surveying. Two surveys of 1.5% of the total population were conducted in April 1992 and April 1995, in conjunction with the Centre for Health, Education and Social Sciences (Monash University, Gippsland). The questions were designed to determine changes in knowledge, attitudes and practices and were modelled on questionnaires developed for the evaluation of a similar commUnity-basedinjury prevention program. Differences between responses in the pre and post-interventionsurveys were tested using the chi-square function in Excel.

Program records, and data from other organisations, including VicRoads, the Liquor Licensing Commission, were also used in the impact evaluation.

Outcome evaluation was intended to include three sources of injury data: self-reported injury, emergency department presentations and hospital admissions. However, hospital admissions data presented significant methodological difficulties and was therefore not used. This had a

LATROBE VALLEY BETTER HEALTH PROJECT Xl significant disadvantage for the evaluation, since the hospital admissions data provided the opportunity for comparison of injury trends with other similar areas of Victoria. The other sources of injury data did not provide a similar opportunity.

Self reported injury data was gathered in the random household telephone surveys. Injury rates for the two week period were calculated using the total population surveyed as the denominator.

Emergency department presentations data for five years (1991/92 - 1995/96) was obtained through the Victorian Injury Surveillance System (VISS) operating at both campuses of the Latrobe Regional Hospital, the only public hospital within the relatively well defined geographic area of the Latrobe Valley. VISS captures high known proportions of patients who present with an acute injury to the emergency department. There were no emergency department surveillance data for a comparable time period available for any other Victorian non-metropolitan region which could be used for comparison.

Data for targeted and untargeted injury categories were extracted by age group, for those residing in program post code areas. The untargeted injury category served as a type of comparison since it encompasses injury not targeted by the program or by other sectors (such as transport and occupational injury). Injury frequencies were adjusted for annual capture rates at each campus of the hospital. Injury rates per 100,000 population were calculated using the Australian Bureau of Statistics resident population estimates and were age standardised by the direct method to the Victorian population.

Two other sources of outcome data were used to evaluate the program component relating to alcohol misuse among youth. Data for fatal and serious casualty crashes among those up to 25 years of age for the program region and comparison regions in rural Victoria were extracted from the VicRoads Crash Database for the years 1984-1995. The data used were limited to high alcohol hours ie., periods during which fatal and serious casualty crashes are 7 times more likely to involve blood alcohol contents exceeding 0.05%. Drunk and disorderly arrests by age, sex and postcode of residence were collected by the Victorian police regional headquarters.

Trends in emergency department presentation rates, motor vehicle crash rates, and drunk and disorderly arrest rates were modelled using established regression techniques. Program effect was assumed to be cumulative in nature, based on Swedish theory of community based injury prevention.

In all the statistical analyses, p values less than 0.05 were considered to be significant. In this evaluation, therefore, a statistically significant result has only a 5% probability of occurring by chance alone. The outcome of a statistical test is not in itself definitive, and should be considered with all other relevant information.

Cost per injury prevented was calculated from the total direct program costs and an estimate of the number of injuries prevented, assuming that the injury rate would have remained constant at the pre-program level, in the absence of the program. The difference between the total expected injury frequency and the actual injury frequency was reduced by 7.9%, to account for the background injury reduction observed in non-targeted injury.

Xli MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Results A range of promotional, educational and awareness raising activities were undertaken in the home, playground and sports injury areas. There were at least 46,000 educational contacts with the community on the subject of home injury prevention of which 1% were structured educational sessions. In addition, home injury prevention education sessions for professional groups were attended by 170 people. There were more than 6000 resource items distributed and consistent media exposure was obtained. Strategic educational sessions were undertaken on the subject of playground safety with the Latrobe Valley Primary Principals' Association and tertiary education students. Injury prevention materials have been incorporated into the local football coaching courses and trainers programs, which reached approximately 365 coaches and trainers. A major sports sponsorship promoting sports safety was secured.

These activities appeared to result in an increase in community awareness, with significant changes in some knowledge measures. A significantly higher proportion of respondents in the post intervention survey was able to list safety features of their home (65.9%, 79.3% p<0.05), however, there was no significant difference in the numbers of features reported per household (1.9, 2.2 p=0.83). Seventy-two percent of respondents in the post-intervention survey reported knowing where to purchase safety items, compared with 62% in the pre• intervention survey (p<0.01). This improved knowledge did not appear to have been translated into action, with similar proportions of respondents reporting that safety items for the family or house had been purchased in the previous 12 months (42.7%, 45.8%, p=O.55).

Unsafe playground equipment was removed and playground undersurfacing was upgraded. In the former City of Traralgon, one new playground per year has been constructed and a total of 6-7 pieces of hazardous equipment removed. Undersurfacing was replaced if necessary twice each year, and more frequently in heavily used areas. In the former City of Moe, 5 new playgrounds were built, and new equipment was installed in 3-4 playgrounds . The former City of Morwell implemented its already existing strategy which required a playground to be located within 500 metres of every household. Since the formation of the new Shire, over $100,000 has been expended on tan bark undersurfacing for municipal playgrounds, and a maintenance crew conducts monthly playground audits using tick box check lists.

The use of safety devices and equipment was increased for some sporting activities, particularly football. The demand for helmet use in junior football has increased, as has the availability of mouth guards.

Injury reductions were observed in both self-reported injury and emergency department presentation data. There was a non significant decrease in the rate of self reported injuries recorded in the telephone surveys (62.711000 persons, 48.2/1000 persons, p=O.19). The age standardised rate per 100,000 persons for emergency department presentations for all targeted unintentional injury fell from 6594 in the first programmed year to 4821 in the last evaluation year. This decrease was significant in the Poisson regression analysis (p=0.017), in contrast to a non-significant decrease observed for non-targeted injury (p=0.08). In the logistic regression analysis, the decreasing trend in all targeted unintentional injury was significantly different to that observed for untargeted unintentional injury, among all age groups tested (0-4, 5-14, 15• 24,25-64,65+ years).

LATROBE VALLEY BElTER HEALTH PROJECT Xlll There were decreases in emergency department presentations for each of the targeted unintentional injury categories, which were significant for:

• home injuries among all age groups except those 65 years and over • playground injuries among 5-14, 15-24, and 25-64 year olds • sport injury among 15-24 year olds only

The reductions were of borderline significance for playground equipment injury emergency department presentations.

In the area of alcohol misuse among youth, working parties were established in collaboration with the Police Community Consultative Committees, through which a range of initiatives were undertaken, these included increasing the acceptance and availability of non/low alcohol alternatives with promotions at 20 major events, responsible serving of alcohol courses in which 35 staff from 10 local venues participated, participation in a code of conduct by all licensed premises in the area, and changes in local legislation prohibiting consumption of alcohol in central business districts.

The impact of these activities on alcohol misuse was difficult to determine with the measures used. Litres of regular alcohol purchased by retail liquor outlets in the program region decreased marginally, while light alcohol purchases increased by 16.5%. In comparison, in country Victoria, purchases of both regular and light alcohol products have decreased by 4.8%. There were non significant increases in the rates of arrest for being drunk and disorderly for both the 15-24 year age group (targeted with alcohol misuse programs) and the over 25 year age group. There were significant decreases in the age group crude rates of motor vehicle crashes during high alcohol times in the both the program and comparison regions of Victoria. In both regions, the decrease occurred during the pre program years.

There were however, significant reductions in intentional injury emergency department presentations for the 10-24 year age group, in contrast with a non significant decrease for those over 25 years.

The direct program costs per injury saved were $272. This does not take into account the considerable in kind contribution of personnel and resources from local organisations. Nor does it include the unpaid additional hours worked by the program officer. There was insufficient data for pre-program years to determine the likely injury rate trend if the program had not been implemented. The estimate was made assuming that the rate of injury would have remained constant at the 1991/92 level in the absence of the program. The number of injuries prevented would therefore have been underestimated if the trend in targeted injuries were increasing, and over-estimated if the trend in targeted injuries was decreasing more rapidly in the absence of the program than that for untargeted injuries, which is unlikely.

Overall the program achieved the aims of utilising a community intervention approach, developing collaborative relationships with local organisations and achieving some structural and organisational changes which had the potential to provide cumulative benefit. There is some evidence that components of the program have been incorporated into the activities of other local organisations, with the program itself ultimately becoming part of the new local government structure.

XIV MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Discussion Evaluation design and methods: Despite some limitations, mainly relating to the absence of a comparison community and comparable injury data, the evaluation design and methods have been strengthened by a number of features including the use of process, impact and outcome measures, the combination of qualitative and quantitative methods, and a relatively small likelihood of contamination from neighbouring programs and activities. One of the strongest features of the evaluation is the prospective injury surveillance system operated at the Latrobe Regional Hospital by the Victorian Injury Surveillance System (VISS). The data collection method remained unchanged for the five year period and regular audits identified the capture rates for both campuses of the hospital, allowing adjustment for variations in capture. The coding system used by VISS allowed disaggregation of the data into the same categories targeted by the program. Age standardisation of injury rates adjusted for population changes during the course of the program, an important feature since the Latrobe Valley has undergone some characteristic demographic changes during the program period.

The emergence of comparable results from two statistical approaches each making slightly different assumptions about the emergency department data indicates a degree of robustness in the finding of injury reductions.

Program objectives and injury reductions: The majority of program objectives, that were evaluated, were met to some extent and there were examples where the program objectives were expanded as opportunities arose. It should be noted however, that none of the stated program objectives extended to include quantitative targets. Therefore, while there is evidence that most objectives were met, there is no measure of the extent to which the objectives were met and some objectives were met for a limited period of time.

Injury reductions were observed in both self-reported injury and emergency department presentation data for all of the three targeted unintentional injury categories. Changes in patient presentation patterns or capture rates are unlikely to account for the decreases, which appear to be real.

The important question for the Latrobe Valley Better Health Injury Prevention Program then, and for injury prevention more generally, is whether all or part of these reductions can be attributed to the program. In the absence of a comparison region, two other avenues can be explored. These are firstly changes in risk or protective factors which could have led to the injury reductions, and secondly changes in non-targeted injury.

There is some evidence to suggest an association between program activities and the observed reductions in targeted unintentional injury emergency department presentations. Awareness of household safety features increased, as did knowledge about where to purchase safety items. There was no evidence though for any increases in knowledge about how to improve home safety, numbers of safety features per house, or the proportion of households having purchased safety items in the preceding 12 months. Consequently, if the significant reductions in home injury emergency department presentations are attributable to the program, the mechanism was behavioural, rather than environmental, modification.

LATROBE VALLEY BETTER HEALTH PROJECT xv instances the hazardous equipment was replaced, and in two former municipalities the amount of playground equipment actually increased. Reduced exposure could therefore only explain the injury reductions if there was a decrease in playground use by the community, which is unlikely.

Changes in risk and protective factors for sports injury are more difficult to detect. There was some evidence for a change in the culture of sports clubs, with an increased emphasis on safety being incorporated. The use of protective equipment, particularly in junior football, appeared to increase. Although the reduction in sport injury emergency department presentations was statistically significant for 15 - 24 year olds only, there is some evidence that the reduction could be attributed at least in part to program activities.

The conclusion that the injury reductions are associated, at least in part, with program activities is supported by three additional observations:

• the reductions were significant in both statistical models in the two program areas in which activities were implemented for a longer period ie., home and playground • the reductions were incremental from the first program year for home and playground injUrIeS • a small insignificant reduction was observed for non-targeted injury

An association between program activities and any decrease in alcohol misuse by young people is more difficult to determine, due in part to imperfect measures. There was no significant reduction in serious injury motor vehicle crashes in high alcohol hours in the program region compared to other rural areas of Victoria. This may be more due to changes in drinking and driving patterns among young people across Victoria, than due to changes in alcohol misuse. There was, however, a marked reduction in the rate of intentional injury by others among 10-24 year olds, compared to little change in the rate for those over 25 years. This is an encouraging result, although it may be due to factors other than a decrease in alcohol misuse.

Future directions: The program has been re-named La Trobe Safe Communities and incorporated into the local government structure, bringing new challenges and opportunities. There would be considerable merit in building on the increased levels of awareness, knowledge and training by increasing the emphasis on environmental, legislative and policy changes, particularly in the home and sports injury prevention components. The incorporation of the program into local government provides the opportunity to examine all aspects of local government operations with a view to incorporating safety into routine activities and services.

Given the encouraging results of the evaluation to date, there is also merit in monitoring the impact of the ongoing injury prevention program, only with improvements to the evaluation design, as there would be little additional benefit in continuing with the current design. These should include a comparison community in which changes in injury risk and protective factors are measured and retrospective and prospective injury data is available.

XVI MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE The continued availability of high quality emergency department injury surveillance data from the Latrobe Regional Hospital is critical, not only for continued evaluation, but also for program implementation. Local injury data has been a powerful motivating tool for the program, and a cornerstone of the evaluation.

Institutionalisation of program components and activities into local government, and into other relevant local organisations, should be monitored and evaluated.

It would be highly desirable to extend the cost benefit analysis of the Latrobe Valley program, using more sophisticated methods building on other current MUARC research. Regardless of the size of injury reductions achievable with this approach, the investment in such programs should be justifiable at least in terms of financial returns. Such a study would provide significant results for the field of community based injury prevention nationally and internationally.

Further evaluations of the type reported here will provide reducing returns. The limitations of the quasi-experimental design, even if a comparison community is included, are significant. Future developments should focus on controlled trials of multiple communities randomly assigned to treatment and control groups, consisting of more than one community. The financial and logistical considerations of such a trial would be substantial and challenging.

LATROBE VALLEY BETIER HEALTH PROJECT XVll

1. INTRODUCTION

The community based approach to all age all injury prevention has been applied increasingly in various parts of the world, following the fIrst successful reports in Sweden during the early 1980's (Schelp 1987a, Moller 1991, National Safety Council of Australia 1992, Gielan and Collins 1993). The early Swedish programs focussed on all types of injury among all age groups. This approach has also been applied to specifIc age groups and injury types (eg., Guyer et al1989, Davidson et al 1994, Jeffs et a11993, O'DonneIl1993, Bablouzian et alI997).

The defIning characteristic of the Swedish community based injury prevention project was a combination of the community-controlled (top-down) approach with the grassroots controlled (bottom-up) approach (Schelp, 1988). The community-controlled approach in this model means that the activities are initiated by established local organisations, in contrast to the grassroots controlled approach which refers to activities initiated by the citizens themselves. According to this model, working through the local organisations is used as a starting point for initiating community work. Individuals from the community become involved in assisting with problem definition, and as necessary knowledge and skills are acquired, increasingly take more responsibility for parts of the program. (Schelp, 1988). An additional characteristic thought to be central to the program's success is that of synergy. By targeting all age groups and all injury types, the various activities within the program combine synergistically to produce a greater effect than that which would be produced by a series of individual projects (Schelp 1987b)

Other programs have followed, and various health behaviour change and community-organising theories, such as social learning and diffusion, have been utilised to provide the theoretical base and structure for these programs (Bracht and Kingsbury 1990, Rifkin 1985, Green and Kreuter 1991).

Controlled evaluations of community based all age all injury prevention programs overseas have identifIed varying degrees of success with respect to the intended health outcome ie., frequency and severity of injury. SignifIcant decreases in injury have been reported in Sweden and Norway relative to comparison communities (Schelp 1987a,b, Svanstrom et al 1995a,b, Ytterstad and Wasmuth 1995a,b, Ytterstad 1995 a,b). In two of the programs, there was some differential effect on targeted injury categories only, and there was a dose-response effect in three programs in the sense that the impact on injury appeared to increase as the program time period increased. However, the reductions in injury achieved in these programs were not shown to be well associated with changes in injury risk or protective factors.

In Australia, there has been one controlled evaluation of an all age all injury prevention program, the Safe Living Program undertaken in the former Shire of Bulla, Melbourne. There were no signifIcant decreases in hospital admissions or presentations after the fIrst three years of program operation. However, there was a signifIcant decrease in rate of households reporting injury, relative to the comparison community, reported for a 2 week period in a telephone survey of 05.-0.8% of the population (Ozanne-Smith et al 1994). After six years (1991-1996), the evaluation of the Safe Living Program has been unable to demonstrate a reduction in serious injuries compared with the comparison community, though the evaluation was complicated by changes to injury data collection systems and to populations. Self-reported injury data, for the previous 2 weeks, showed a statistically signifIcant reduction for households, and close to a signifIcant reduction for individuals in households when compared with pre-intervention and comparison community data. The majority of self reported injuries required no medical treatment and did not cause interruption to normal activities (Ozanne-Smith, 1997).

LATROBE VALLEY BETTER HEALTH PROJECT 1 Comparative data is not always readily available, nor are sufficient funds always provided to conduct controlled evaluations. Consequently, there are some programs which have reported injury reductions, in the absence of comparative data (eg., Tellnes 1985, Jeffs et al., 1993). In these circumstances, however, the evidence for the effectiveness of this approach to injury prevention is not always convincing.

Further, no published studies have reported even a crude cost per injury prevented in order to gain some appreciation of the cost-effectiveness of community based injury prevention programs. An estimate based on one Swedish program suggested that, despite statistically significant injury rate reductions, a relatively small number of non-fatal injuries were prevented (Langley and Alsop 1996).

This document reports on the evaluation of the first four years of the Latrobe Valley Better Health Injury Prevention Program, a community based program, modelled on the Swedish experience, in the Latrobe Valley, Victoria. There is no comparison community, due to budgetary constraints. However, changes to injury risk and protective factors have been measured, and comparative data was available for some impact and outcome measures. In addition, a crude cost per injury prevented has been calculated.

Minimal information is provided on the injury prevention program history, structure and implementation which are comprehensively covered by the program officer's report (Harberts 1997). Evaluation methods are covered in some detail. Process, impact and outcome results are presented for each of the four targeted issues, while the assessment of strategic links with local organisations, and indicators of institutionalisation and sustainability are presented in separate sections. Injury outcome data is presented in the sections relating to the targeted areas, and is also collated in a separate section.

2 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 2. PROGRAM STRUCTURE

2.1 AIMS AND OBJECTIVES

The Latrobe Valley Better Health CLVBH) Project arose from the Latrobe Valley Health Study conducted in 1990 and a series of subsequent community consultations, meetings and forums. Funding was received from the Victorian Health Promotion Foundation for a project which would address the two issues of nutrition and injury. The main aim and objectives of the injury prevention program as initially described are shown below:

Aim To utilise a community intervention approach to prevent injuries, reduce hazards and increase public awareness of measures to reduce the incidence and severity of injuries in the Latrobe Valley community.

Objectives • to increase community awareness of injury prevention and create a "safe Community" environment

• to develop and implement strategies which will provide an overall reduction in the number and severity of injuries within the Latrobe region

• to reduce the number of hospital bed days incurred as a result of injuries

• to reduce the incidence of death due to injury

• to reduce hazards

• to increase the use of safety devices and equipment

The injury prevention program focussed on four main areas of activity: home, sports and playground injury prevention, and alcohol misuse among the youth. Aims and objectives were developed for each of these four areas, and are reproduced under each area of activity in the results section for ease of reading. The initial aims and objectives changed little during the evaluation period, with some additional activities being undertaken as opportunities arose.

2.2 COMMITTEES AND WORKING GROUPS

The Latrobe Valley Better Health Project (incorporating both the injury and nutrition programs) was auspiced by the former Morwell Community Health Centre and was managed by the Latrobe Valley Better Health Management Committee, representing local government, industry and health agencies. A reference group, reporting to the Management Committee, was established to direct the injury prevention program and as momentum gathered, three working groups were convened in the areas of home, sports and playground injury. The three Police Community Consultative Committees for the areas of Moe, Morwell, and Traralgon in effect became the working groups for the alcohol and youth area of activity.

LATROBE VALLEY BETIER HEALTH PROJECT 3 2.3 IMPLEMENTATION

The program was based on a number of health promotion models, particularly the Bracht and Kingsbury model (Bracht and Kingsbury, 1990), and incorporated the principles of injury prevention at the local level as described by the successful Swedish program (Schelp, 1988). The guiding principles included community ownership, synergy between program components, and structural change which would provide a cumulative benefit (Harberts, 1997).

A program officer dedicated to the injury prevention program was employed full time from May 1992 to June 1996 and beyond. A prominent feature of the injury prevention program was the working partnerships developed with a wide range of local organisations strategically placed to assist with the implementation of the program strategies.

The program officer, while employed by the Morwell Community Health Centre, operated from an independent office, and was responsible to the working groups, the injury reference committee and the Latrobe Valley Better Health Management Committee.

4 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 3. EVALUATION METHODS

3.1 EVALUATION DESIGN

The evaluation is a quasi-experimental uncontrolled design which includes pre and post intervention observations. The evaluation is uncontrolled in the sense that there is no single comparison community in which a range of equivalent measures have been recorded. Insufficient funds were available to enable this to occur. However, where possible, comparative data from a range of sources has been included.

The current evaluation covers the period from May 1992 to June 1996, although the program has continued to operate since June 1996. Three generally recognised phases of evaluation are included, each of which relates to the program goals, objectives and strategies (Table 1) (Green and Lewis 1986, National Committee for Injury Prevention and Control 1989, Hawe et al1990; Borland 1992). The evaluation incorporated the experience of evaluating the ftrst three years of another similar Victorian program (Ozanne-Smith et al., 1994).

Table 1: Evaluation phas~s, Latrobe Valley Better Health Injury Prevention Program, 1992-1996

Program Plan Evaluation Phase Example measures Goal Outcome reduction in injury incidence and measurement of long term injury incidence, rates and severity in the community effect severity Objectives Impact relate to achieving quantifiable measurement of immediate knowledge and attitude; changes in injury risk and effect hazards and safety features protective factors in physical environment Strategies Process plans to achieve the changes in measurement of program implementation of risk factors delivery and execution of activities; the strategies participation in program activities; reach of program activities

3.2 PROCESS EVALUATION

Reports to the Management Committee, the program officer's diaries and the program media ftle were available for analysis. Information was also gathered directly from a range of local organisations which had been involved in the implementation of program activities. Some program activities were conducted as projects within the program and had separate reports, which also became sources of information for the evaluation. A random household telephone survey conducted in 1992 and 1995 provided some data relating to awareness of safety programs, and recall of the LVBH project in particular. Details of the survey method are found in Section 3.3.1.

LATROBE VALLEY BETTER HEALTH PROJECT 5 An interview with the program officer was conducted towards the end of the evaluation period to gather supplementary information.

Four key informant interviews were conducted with representatives of organisations involved with the sport, playground and youth alcohol program activities, to determine the extent to which the program had been successful in forming strategic links with local organisations. The fourth interview was conducted with a representative of local government, which had been involved with a number of activities across the four program areas. Since working collaboratively with local organisations was proposed as a feature central to the successful Swedish programs, the results of the key informant interviews are presented in a separate section.

3.3 IMPACT EVALUATION

3.3.1 Telephone survey Random household telephone surveying was a major method utilised for the impact evaluation. The telephone surveys also produced some data used in the process (program awareness), and outcome (self-reported injury) evaluation phases.

Two surveys, in April 1992 and April 1995, were conducted in conjunction with the Centre for Health, Education and Social Sciences (Monash University, Gippsland), which was responsible for the evaluation of the nutrition program of the LVBH project (Harvey and Higgins, 1997). The 1992 survey was conducted prior to program commencement and will be referred to as the pre• intervention survey. Although the program continued through 1996 (and continues), for convenience, the 1995 survey will be referred to as the post-intervention survey.

Since the questionnaire was to cover the areas of both injury and nutrition, the number of possible questions was limited. The injury questions were modelled on a pre-intervention questionnaire developed for a similar community-based injury prevention program in the Shire of Bulla (Ozanne• Smith et al., 1994). The questions were designed to determine changes in knowledge, attitudes and practices. The pre and post intervention survey forms are found in Appendix 1.

Sampling Frame Two random samples were drawn independently from a sampling frame defined by the 051 listings in the Telstra White Pages Telephone Directory. Numbers were selected by a pre-determined process ie., the first number in every fourth column. Apparent business numbers were discarded. Up to four attempts were made with each number before discard. The connection rates for the two surveys were similar, however the response rate was much lower in the second survey (Table 2). The population surveyed at each time point represented approximately 1.5% of the total population (Table 2).

There were some demographic differences between the respondents in the two surveys. In the post• intervention survey, there were significantly more self nominated country dwelling respondents (8.0%, 14.5% p

However, there was no statistically significant difference between the postcode distribution (p=0.69), the age groups of the respondents (p=0.92), the number of adults per household (p=0.27),

6 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE the number of adults over 65 years of age (p=0.48), or the proportion of rented homes (19.7%, 19.8% p=0.92) (Appendix 2).

Table 2: Telephone surveys, Latrobe Valley Better Health Project evaluation, Victoria

Post-intervention,4001.6%118255.5%199581.% Pre-intervention,76.8%76.7%1.4%1052375 1992 personsproportionconnectionresponsehouseholdsratetotalrate population

The questionnaires were coded for data entry after completion of the surveys. The amount of information lost in the coding process was minimised by discrete coding of responses rather than allocation to a category. The data were analysed using SPSS.X Version 4.1 to generate frequency listings and cross tabulations.

3.3.2 Other methods

Program records, and those of other organisations, were also used in the impact evaluation. Volumes of liquor purchased annually by retail licensees in the Latrobe Shire and all Victoria were obtained from the Liquor Licensing Commission. Data were available for the categories of light beer, ordinary beer, light wine, ordinary wine, and spirits. These volumes represent the amounts purchased by the retail outlets, and are therefore a proxy for the volumes consumed by the population. Large re-stocking activities by one or two outlets in a relatively small area such as the Latrobe Valley may result in considerable year to year variations.

3.4 OUTCOME EVALUATION

3.4.1 Definition of program region

The region in which the program operated during the evaluation period was defined by the former Victorian local government areas of the Cities of Moe, Morwell and Traralgon, and the Shire of Traralgon. The program region for the purposes of the evaluation was generally defined on the basis of postcode (Table 3). Some exceptions to this were made for the injury outcome data analyses, and these are discussed in the relevant sections below. The population of the program region increased from 75,500 to 76,560 during the evaluation period.

3.4.2 Self reported injury

Self reported injury data was gathered in the random household telephone surveys. Respondents were asked to recall injuries sustained by household members during the 2 weeks immediately preceding the telephone interview. Information on the activity, location, circumstances of all reported injuries was collected in addition to the level of medical treatment required. Injury rates for the two week period were calculated using the total population surveyed as the denominator.

LATROBE V ALLEY BETIER HEALTH PROJECT 7 Table 3: Latrobe Valley Better Health Injury Prevention Program region, Victoria, 1992• 1996

Local Government Area Postcode (pre 1995) City ofMoe 3825 City of Morwell 3840,3842,3869,3870 City of Traralgon 3844 Shire of Traralgon 3844

Table 4: Data sources for the injury outcome analyses, Latrobe Valley Better Health Injury Prevention Program, Victoria, 1992-1996

Database/sourceTime residentialperiodlocalpostcodeNumeratorresidential2ABSpersonsnumberpresentationsresidentdepartmentall1991-19961987-1996emergencyhospitaladmissionsweeksdenominatorselfPopulationgovernmentInjuryestimatedreportedofInin each postcodearea population by population for InpatientMinimumSurveillanceSystem Dataset of 1992 & 1995 extracted by householdspostcodeareasareas)localsurveyedstatisticalgovernment(matchedlocal to TelephoneVictoriansurveyInjury

3.4.3 Emergency department injury presentations The Victorian Injury Surveillance System (VISS) operating at both campuses of the Latrobe Regional Hospital, was the data source for emergency department injury presentations. Detailed descriptions of the data collection process and the VISS database have been published elsewhere (Nolan and Penny, 1992; Watt, 1992). Briefly, a standard injury surveillance questionnaire was used to gather patient demographic data, injury circumstances and cause data, and injury diagnosis and treatment data. Different sections of the questionnaire were completed by the patient (or accompanying person or nursing staff), and the medical staff. The completed questionnaires were then coded by two trained data coders according to a nationally accepted coding framework (National Injury Surveillance and Prevention Project, 1988).

8 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE All patients presenting with an acute injury were given a questionnaire to complete, on their first attendance for that particular episode. Therefore both presentations and admissions are included in the VISS database. Regular audits of the emergency department log books were conducted to establish capture rates (Table 5). Admitted cases not captured prospectively were entered retrospectively from the department records, effectively resulting in a 100% capture rate for admissions.

Table 5: Capture rates (%), Victorian Injury Surveillance System, Latrobe Regional Hospital, 1991/92-1995/96

Year Latrobe Regional92.4%90.0%85.0%97% Hospital85.0%85.0%LatrobeMoeCampusRegional Hospital 1992/931994/951995/961993/941991/92 Traralgon Campus

Five complete years of emergency department injury surveillance were available for analysis (July 1, 1991-June 30, 1996). After June 30, 1996, injury surveillance at Latrobe Regional Hospital changed significantly from the paper based method to routine electronic surveillance (Watt and Ozanne-Smith 1996). The completeness and quality of the electronic surveillance at Latrobe Regional Hospital has not been established and therefore is not used in this evaluation. The Latrobe Regional Hospital is the only public hospital within the relatively well defined geographic area of the Latrobe Valley. This hospital services 88% of Latrobe Valley residents who require hospital admission (Penny et al., 1992).

There were no emergency department surveillance data for a comparable time period available for any other Victorian non-m~tropolitan region which could be used for comparison. Similarly, there were no all age emergency department injury surveillance collections in non-metropolitan regions for this time period elsewhere in Australia.

The data were analysed using the Injury Surveillance Intelligence System to generate frequency distributions for the variables of interest. Data relating to patients who did not reside in the program region were excluded from the analyses on the basis of residential postcode. Selection criteria for the different injury categories are shown in Table 6. The category of other unintentional injury excludes home, sport, playground, work and road traffic accidents. This category serves as a type of comparison since it encompasses injury not targeted by the program or by other sectors (such as transport and occupational injury).

Injury frequencies were adjusted for annual capture rates at each campus of the hospital. Injury rates per 100,000 population were calculated using the estimated resident population for the program postcode areas purchased from the Australian Bureau of Statistics. Estimates were only available for the years 1991 to 1994. Population estimates for program postcode areas for 1995 were generated by applying the 1995 combined growth rate for the relevant statistical local areas to the 1994 ABS postcode area estimates. Population estimates for 1996 were similarly generated by applying the

LATROBE VALLEY BETTER HEALTH PROJECT 9 1996 combined growth rate for the relevant statistical local areas to the 1995 postcode area estimates. Published growth rates by statistical local area for 1995 and 1996 were used in these estimations (Australian Bureau of Statistics 1995, 1997).

Table 6: Selection criteria for injury data extraction, Victorian Injury Surveillance System, Latrobe Valley Better Health Injury Prevention Program, Victoria, 1992-1996

Injury category victimallplaygroundworkinvolvedsporthomeunintentionalasSelectionastypeactivitylocationin eventequipmentasorganisedplaygroundpedestrianprivate/commercialonbicyclistinformalfox,intendedinside,ownlocalslides,locationcriteriadutyminusand/orswings,home,Includesgovernmentsee-saws,garage,orviolencesportashome,competition/practiceoninjuryotherequipmentfactortreehouses,otherbreakyardmonkeyprivatefacilitiesbetweenareasandat workgardenexcludeshomebars,persons,flyingself harm equipmentpersonsother unintentionalcause motorcyclistplayground,daycarencindergartensothercartrafficsportschoolspassengernotpublicaccidentsspecifiedparksport, work, road home workplayground roadintentional-betweensport traffic accidents

3.4.4 Injury hospitalisations

The Victorian Inpatient Minimum Database (VIMD) holds information relating to all Victorian public hospital (and more recently private hospital) admissions. At the time of this evaluation, VIMD data was available for the 9 financial years 1987/88-1995/96. Injury data in the VIMD for this whole period cannot be analysed on the basis of location, activity, or associated products to provide specific information relating to home, sports and playground injury. The VIMD does, however, include injury hospitalisation data for other hospitals in Victoria, providing the opportunity to conduct overall comparisons, including a number of pre-program years.

10 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE MUARC holds, by agreement with the Victorian Department of Human Services, a subset of VIMD records, selected by external cause of injury codes (E codes) from the International Classification of Diseases Ninth Revision Clinical Modification (Commission of Professional and Hospital Activities, 1986). The subset encompasses a range of variables for each injury hospitalisation, including age, sex, and external cause of injury. Geographic identifiers include postcode of residence and local government area. Australian Bureau of Statistics estimates of resident population are not available by postcode of residence prior to 1991. However, these estimates are available for SLAs, which have a defined relationship to LGAs and can therefore be used to derive LGA population data. Therefore, the local government area variable in VIMD was used to extract data for the Latrobe Valley program region, and for a comparison region.

The comparison region was defined according to the Rural, Remote and Metropolitan Areas Classification System (Departments of Primary Industries and Energy, and Human Services and Health 1994) This system classifies all statistical local areas (SLA's) into one of three groups and seven categories within these groups based on population density and an index of remoteness (Table 7).

Table 7: Summary of the Rural, Remote and Metropolitan Areas Classification System Structure

Group Zone Category

Metropolitan areas capital city other metropolitan centre Non-metropolitan areas Rural large rural centre small rural centre other rural centre Remote remote centre other remote area

Source: Departments of Primary Industries and Energy, and Human Services and Health, 1994

The comparison region for hospital admissions data is comprised of Victorian rural areas which fall into the same category as the program region ie., small rural centres. A listing of these SLAs and their corresponding local government areas for the program and comparison regions can be found in Appendix 3.

Injury rates for the Latrobe Valley program region and Victorian small rural centre areas, were calculated using the estimated resident population data for SLAs for the years 1987 to 1994, purchased from the Australian Bureau of Statistics. Population data for the years 1995 and 1996 were estimated using published SLA growth rates as described in Section 3.4.3.

3.4.5 Motor vehicle crash data

Data for fatal and serious casualty crashes which occurred in the program region and which involved persons with a program region postcode of residence were extracted from the VicRoads Crash Database for the years 1984-1995. Data were also extracted for crashes in Victorian small rural centres, the comparison region described in Section 3.4.4. The data for program and

LATROBE VALLEY BETTER HEALTH PROJECT 11 comparison regions were then stratified by high and low alcohol times, and by age group (up to 25 years and over 26 years). The high alcohol hours of the week are those periods when drivers involved in fatal and serious casualty crashes are 7 times more likely to have a blood alcohol content exceeding 0.05% (Newstead et al., 1995). Annual rates were calculated using the estimated resident population for statistical local areas (matched to local government areas) as described in Section 3.4.4 for the denominator. The rates calculated are therefore only estimates as the rate numerator for both the program and comparison regions will include non-residents.

3.4.6 Drunk and disorderly arrests

A purpose designed system for the recording of drunk and disorderly arrests was devised and implemented by the Victorian police regional headquarters to support the program evaluation. Monthly log sheets were kept in each of three watch houses (Moe, Morwell and Traralgon) on which the age, sex and postcode of residence of each person arrested for drunk and disorderly behaviour was recorded prospectively from June 1992 to June 1996. Data for the period April 1991 to May 1992 were gathered from the police records retrospectively. The monthly log sheets were forwarded to MUARC for coding, entry and analysis at regular intervals. Annual rates were calculated using the estimated resident population for program postcodes as described in Section 3.4.3.

3.5 STATISTICAL ANALYSES

Differences between responses in the pre and post-intervention surveys were tested using the chi• square function in Excel.

Trends in emergency department presentation rates, motor vehicle crash rates, and drunk and disorderly arrest rates were modelled using established regression techniques assuming a Poisson error structure for the rate data, an accepted model for injury rate data (Svanstrom et al., 1995b, Watt and Ozanne-Smith, 1996, Langley and Alsop, 1996). Regression analysis was conducted using the GENMOD procedure for the SAS statistical analysis package (SAS Institute Inc., 1993).

Injury rates were age standardised by the direct method to the Victorian population (pollard et al., 1981) ..

Modelling was conducted for injury hospitalisation rate data (which included a comparison region) using the Generalised Linear Models package to perform logistic regression assuming a binomial distribution for the data (Hosmer and Lemeshow, 1989). The binomial distribution was chosen because the outcomes (injury, no injury) are mutually exclusive. Injury data does not quite meet the two other major characteristics of the binomial distribution, ie., the probability of injury remains constant, and an injury outcome at one point is not dependent on an injury outcome at a previous point. However, the impact of changes in injury risk to individuals over time, and the possibility that one individual may present more than once in a given time period, is likely to be minimal in a large population.

Other evaluation studies of community based interventions have assumed either a Poisson or normal distribution (Svanstrom et al., 1995b; Langley and Alsop, 1996). However, it is likely that this injury data may have characteristics of at least two, and possibly, all three distributions (Hunley and Choi, 1996). Ultimately the binomial distribution was chosen here for its greater simplicity in developing the model and because the fit to the binomial distribution is likely to be as good as any

12 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE other, a prediction which had been observed in the evaluation of another community-based injury prevention program (Ozanne-Smith, 1997).

For the modelling of injury hospitalisation data, the dependent variable was frequency of injury, with population being the number of trials from which injury hospitalisations occurred. The independent variables were:

factor: comparison or intervention group (small rural areas or Latrobe Valley) factor: age group (0-4,5-9, 10-14, 15-64,65+) factor: program active (occurs within intervention group only) factor: year (1987/88 to 1995/96)

The method of using age group as a factor in the analysis alleviates the need to age-standardise the data, as differences in the profiles between the treatment and control groups are automatically taken into account.

The modelling of the injury hospitalisation rate data for the program and comparison regions was unsuccessful in that acceptable model fits were not attainable. There was a large degree of year to year by age variation, which was not the same for the program and comparison regions. The most likely explanation for this variation is the impact of case mix funding, which was officially introduced to the Victorian hospital system in 1993/94. Anecdotal evidence indicates a likely influence in 1992/93 as hospitals began to use the case mix funding classifications. The impact of case mix funding on injury hospitalisations-has been observed in other studies (Watt and Ozanne• Smith, 1996, Ozanne-Smith, 1997, D. Dyte, personal communication). In this study, the variation was considered to be large enough to mask any significant program effect. Further, since it is quite feasible that the effect of case mix is not consistent across hospitals, it was not reasonable to persist with the use of hospitalisation data in the evaluation.

Logistic regression was also conducted with the emergency department injury presentation data, in addition to the Poisson trend analysis carried out independently on targeted and non-targeted injury. hi the logistic regression, the model tested for a significantly different trend in targeted injury categories as opposed to other injury during the program years. The dependent variable was frequency of injury. Separate analyses were performed by age group to simplify interpretation.

Program effect was assumed to be cumulative in nature, based on Swedish theory of community based injury prevention.

The model leads to estimates of the odds of an individual being admitted for injury (or presenting to the emergency department) in anyone year relative to a reference year or years. Confidence intervals (95%) were calculated for the odds ratio.

LATROBE V ALLEY BETIER HEALTH PROJECT 13 3.6 COSTS PER INJURY PREVENTED

The total direct program costs were obtained by summing the program grant agreements covering the period April 1992 to June 1996.

Expected annual injury frequency was calculated for each major component (home, sport, playground, violence) of the program by applying the emergency department presentation rate (including admissions) for 1991/92 (pre-program year) to the estimated resident population for the years 1992/93 to 1995/96. The difference between the total expected injury frequency and the actual injury frequency was reduced by 7.9%, to account for the background injury reduction observed in non-targeted injury. The resulting figure is an estimate of the injuries prevented during the evaluation period, assuming that the all injury reduction above the background can be attributed to the program. This estimate does not take into account trends in emergency department presentation rates during the pre-program years, due to the lack of data.

Cost per injury prevented was then calculated from these two figures.

14 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 4. RESULTS

4.1 GENERAL

The injury prevention program has been very successful in attracting and maintaining relatively high levels of local publicity for the program. The local print media ran an average of one article per fortnight on the program, often regarding a specific activity. In addition, there have been at least two large 5-8 page features in the local newspapers, one in 1994, and another in 1996. Commencing in 1996, the program logos have been appearing on the football results page in the local newspaper.

Television coverage was obtained for a number of special events including community health week, child health week, World Health Day in 1993, key events in the sporting calendar, and visits by overseas community safety experts, Dr Gunilla Bjaras and Professor Leif Svanstrom from the Karolinska Institute in Sweden. Significant media coverage was also obtained for the launch of the football helmet trial, and the launch of the Latrobe Valley Falls Prevention Program, the latter resulting in a television interview.

ABC regional radio has provided 10-15 minutes per month since late 1993, including a live to air segment since late 1995. In addition, fortnightly sessions were broadcast on an FM station during 1993-1996.

Publicity relating to some components of the program was also achieved in some specialist publications including the Central West Gippsland Division of General Practice Newsletter, the Yalloum Medical and Hospital Society Members Newsletter, the Victorian Department of Human Services Newsletter "Momentum", and the Family Research Action Centre monthly magazine.

Similar proportions of respondents in the pre- and post-intervention telephone surveys stated that they were aware of safety programs in the area. The difference was not statistically significant (18.7%, 20.8%, p=0.42). The most frequently named programs were St John's Ambulance, Neighbourhood Watch, and general road safety campaigns. In the post-intervention telephone survey, one percent of respondents named the Latrobe Valley Better Health Project, without prompting. When subsequently asked directly if they had heard of this program, 20.3% responded affirmatively. Of the 81 respondents in the post-intervention telephone survey who had heard of the program, the print media was the most frequently cited source (43%), followed by radio (16%).

Similar pre and post intervention surveys were conducted in 1990 and 1993 for the Safe Living Program in the former Shire of Bulla, Victoria. In the post-intervention survey, 44.6% of respondents reported they had heard of the Safe Living Program when asked directly (Ozanne• Smith et al., 1994).

4.2 HOME INJURYPREVENTION

4.2.1 Aims and objectives

Aim To familiarise the community with home safety measures and to reduce the incidence of child injuries by providing a venue where safety design features and safety promotion devices can be demonstrated to the public.

LATROBE VALLEY BEITER HEALTH PROJECT 15 Objectives • to collaborate with the Latrobe Regional Hospital to provide a display of safety promotion in a home setting

• to provide a central location for information on child safety products

• to coordinate the dissemination of information about safety in the home and injury prevention strategies and equipment

• to provide a venue for child safety education

• to provide a venue for health promotion and education needs of parents with young children

4.2.2 Process measures

Safety features display home: The program officer arranged for Glenhaven Homes to construct a Safety Features Display Home, incorporating approximately 50 safety features. The home was available for public inspection for a period of 8 weeks from March 2, 1993, during which time approximately 1000 visitors inspected the house and received a brochure detailing the safety features.

Permanent safety display at Latrobe Regional Hospital: This has been in place in the emergency department reception area at the Traralgon campus since November 1995. The display includes 200 minutes of safety information continuously playing on video. An average of 1738 patients, plus accompanying persons, would be potentially exposed to the display each year. Two out of the three consortia tendering for the new La Trobe hospital agreed to include the safety display in their proposal, after discussions with the program officer.

Home safety training for professionals: La Trobe Shire home care staff, who provide assistance with meals, and household duties to disabled and aged residents, have received training sessions in falls prevention. Repeated attempts to establish the proportion of home care staff who have received this training have not been successful. The training provided was based on the falls prevention training package, developed as part of the Latrobe Valley Falls Prevention Program. Similar training has also been incorporated into the La Trobe Shire Volunteer Training Program.

Silver Circle, a private provider of home care in the Morwell and Churchill areas, has incorporated the falls prevention package into their training program. There are currently 68 Silver Circle home carers, all of whom have completed the falls prevention training. All new staff now receive this training as part of their induction.

The Falls Prevention Program training package has been adopted into the curriculum of three TAFE courses at Newborough: Residential and Community Services, Certificate of Home Care and Advanced Certificate of Home Care. Repeated attempts to ascertain the numbers of people who participate in these courses each year have failed.

Home safety education sessions: A number of general home safety education sessions for both professional groups and members of the public have been conducted (Tables 8 and 9).

Mobile safety product display: This display of safety items and equipment was developed as an educational tool for the community. It has been displayed at three major events each year from 1992 to 1995. The major events were Family Expo, Community Health Week, and Senior Citizens

16 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Week. The display was also used at other events shown in Table 10. The Yalloum Medical and Friendly Society and local pharmacies also had a home falls prevention safety display in their window for a 2 week period.

Table 8: Home safety education sessions for community members, Latrobe Valley Better Health Injury Prevention Program, 1992-1996.

Year MoeMaternalMorwellTraralgonSeniorpublicNursingSeniorCitizenspublicSeniorandpublicSeniorseminarCitizensChildMothersWeekCentresseminarCitizensseminarCitizensHealthGrouponNumberSessionsfallsFallsononnewfallspreventionfallsPreventionofmotherspreventionpreventiongroupSeminars437-44735-402003020401512105 1995/96199319941993199519941993-9619941993 TOTAL participants

Uptake of home safety products and practices: Distribution of hot water measuring devices occurred in conjunction with a Kidsafe project. No separate records were kept for distribution numbers in the La Trobe Valley. A program to install smoke detectors was run in 1994 in conjunction with Confident Living and two Country Fire Authority regions. Approximately 300 people were exposed to this program.

LATROBE VALLEY BETTER HEALTH PROJECT 17 Table 9 Home safety education sessions for professionals, Latrobe Valley Better Health Injury Prevention Program, 1992-1996.

Year LatrobeFamilyMaternalAgedMoeMorwellYalloumGippslandCooindaSilverHomeSkillandCircledayValleyHillHomeMedicalandDisabilityShareFamilycareCareHomestaffChildNurse'sMedicalMaintenancestaffchildWorkersandServicesHealthCarersGroupNumberServicesLaHospitalcareNetworkClinicTrobestudentsanddisabilityStaffPlanningof(fallsCommunityShireSociety(fallsprevention)resourceprevention)AdvisoryNursingBoardHealth165-17215-20of8-1020*352015634 NursesworkersCommittee 199519941995 Management(Services (fallsfallsprevention)prevention) 1994 participants 199519941995/9619941993 TOTAL* An additional 48 have been trained by Silver Circle1995themselves

18 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Table 10: Mobile safety display, Latrobe Valley Better Health Injury Prevention Program, 1992-1996.

Year VictoriaFamilyDisabilityRACVMonashMaternalHeartLatrobeHomeChildren'sCommunitySafeSeniorCommunitiesWeekShowCitizens&ResearchRegionalUniversityonandVicRoadsAwarenessweektheAwarenessHealth(ShoppingChildMoveWeekFamilyActionHospitalWeekGippslandWeekHealthSafetyEventWeekEstimatedcentre)WeekexpoCentrefeteParentDay(Monash(ShoppingHealthYearInformationofUni)andthecentre)Safety>45,790-46,410minminFamily1000-15008000/year200-300days50-6020-301000/year3000200/year70+250800500100 Week numbers 1994199519961995199319941992-951992-95199319931992-95HealthTOTALIssues information night 19951994 exposed

Resource material distributed: Table 11 provides an illustration of the range and numbers of home safety resource materials distributed. It should be noted that some of these resources were designed for limited circulation to strategic organisations and professional individuals.

LATROBE VALLEY BEITER HEALTH PROJECT 19 Table 11: Home injury prevention resource material distributed, Latrobe Valley Better Health Injury Prevention Program, 1992-1996.

Resource material Number

Home safety booklets 150 Child week brochures/stickers 300

Home safety checklist 500 Home safety flier 900 Safety check list for Family Day Care 200 SAFE and RCH Safety Centre materials 200 Poisons information phone number stickers 1000-1500 Falls prevention training package 50 Falls prevention safety audit checklist 2000 Directory of Physical Aid Services (for service provides and care 80 staff) Pamphlet on physical aid services (for general distribution) 1000 Safety in the Home video kits 5 Stay on your Feet book 200 TOTAL >6585-7085

Summary: Over the evaluation period, there have been at least 46,227-46,857 educational contacts with the community (population 75,500-76,560), of which 1% were structured educational sessions. In addition, education sessions for professional groups were attended by 165-172 people. There were more than 6585-7085 resource items distributed and consistent media exposure was obtained.

4.2.3 Impact measures

A significantly higher proportion of respondents in the post intervention survey was able to list safety features of their home (65.9%, 79.3% p<0.05), however, there was no significant difference in the numbers of features reported per household (1.9, 2.2 p=0.83). There was no significant difference between the proportion of households in the telephone surveys able to list ways in which the safety of their home could be improved (50.7%, 47.3% p=0.37).

Knowledge about where to purchase safety products improved during the course of the program. Seventy-two percent of respondents in the post-intervention survey reported knowing where to purchase safety items, compared with 62% in the pre-intervention survey (p<0.01). This improved knowledge did not appear to have been translated into action, with similar proportions of respondents reporting that safety items for the family or house had been purchased in the previous 12 months (42.7%, 45.8%, p=0.55). There was however, a significant difference in the proportion of respondents able to indicate what prompted the safety purchases (14%, 46%, p

20 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 4.2.4 Outcome measures

Self reported injury: There was a non-significant decrease in the proportion of injuries reported in the telephone surveys as occurring in a residential location during a two week reference period (37.9%,28.1 %, p=0.25).

Emergency department presentations (poisson regression): A significant decrease in unintentional home injury emergency department presentations was observed (p=O.OI), in contrast with a non significant decrease in untargeted unintentional injury (p=O.08) (Appendix 4).

The decrease in home injury emergency department presentations was significant in all age groups, except for 65 years and over (Appendix 4).

Emergency department presentations Oogistic regression): The decreasing trend in home injury emergency department presentation rates was significantly different to that observed for untargeted unintentional injury, among all age groups except for those 65 years and over (Appendix 5).

Injury frequencies adjusted for capture rates, age group crude rates and age standardised rates are tabulated in Appendix 6.

5000 4500

3500 -+-home

40001------2000~ ::::::::I~~t::::::::::::::::::------~=------

1000 ------1500500 I------f ------o 1991/92 1992/93 1993/94 1994/95 1995/96 Year

Figure 1 Age standardised unintentional home injury emergency department presentations (including those admitted), LRH 1991/92-1995/96. Other unintentional excludes program targeted injury, road and work related injuries

4.3 PLAYGROUND INJURY PREVENTION

4.3.1 Aims and objectives

Aim To reduce the number of injuries sustained by young children whilst using playground equipment

Objectives • to collaborate with local government to ensure all municipal playgrounds are assessed against safety standards

LATROBE VALLEY BETIER HEALTH PROJECT 21 • to encourage all municipalities to produce a playground strategy which includes mechanisms for regular safety audits

• to inform the community of the nature of injuries associated with playgrounds and to provide them with strategies to avoid such injuries

• to provide injury prevention information to community groups with existing playgrounds and to those designing future play facilities

• to raise community awareness of playground safety issues generally

4.3.2 Process measures

School playgrounds: The program officer has addressed meetings of the Latrobe Valley Primary Principals' Association (40 members) concerning school playground safety in both 1992/93. During the meeting, the Kidsafe Safe Schools program and the benefits of school playground audits were promoted. The Program also initiated a bulk mail out of safety material to local schools through the Directorate of Education in 1993.

The program officer also addressed 12 health and physical education teachers at Drouin in 1995 at a network meeting, distributing brochures and showing a safety video.

Under the school curriculum standards framework, safety is a feature of the physical education and health component. Consequently, the program has been resourcing schools and teachers, with written material and verbal presentations, to assist them in meeting the curriculum requirements. The program officer also had some input into the curriculum framework at the time of the curriculum review.

School safety (playground and sports), presented by the program officer, has been a feature of the Monash University Gippsland Campus Bachelor of Education (primary) course since 1992, with an annual attendance of approximately 60 students. Brochures on School Safe have been distributed each year to these students.

4.3.3 Impact measures

School playgrounds: Until the end of Term 2 1993, a playground safety audit was routinely offered to each primary school by the school nurses. After that time, the audit was replaced by a talk to the principal, as a result of changes to the school nurses role. A review in December 1993 of six audits that had been carried out early in 1993 showed that of the thirteen items noted as unsatisfactory in the audits, two had been addressed. It is worth noting that some schools also attended to other non• playground related safety issues that had not been raised by the audits. In addition, one school reported that safety and injury prevention would become one of the school's priorities under the Schools of the Future Program in 1994. A summary of resources distributed is provided in Table 12.

22 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Table 12: Playground injury prevention resource material distributed, Latrobe Valley Better Health Injury Prevention Program, 1992-1996.

Resource material Number

MUARC report (Hazard) on school injuries to Department of 50 School Education and the Latrobe Valley School Principals School Safe and local playground injury data to local schools - Newborough High School (Year 11, HD&S students) 12 - Kurnai High School (Year 11, HD&S students) 12 - Churchill Primary (Teachers) 12 School safe brochures to education students 300

Municipal playgrounds: As a result of program activities, two of the former local councils, the Cities of Moe and Traralgon, became more focussed on playground safety. In the former City of Traralgon, one new playground per year has been constructed and a total of 6-7 pieces of hazardous equipment removed. Undersurfacing was checked and replaced if necessary twice each year, and more frequently in heavily used areas. During 1992-1994, two formal maintenance reports were produced and three monthly maintenance checks were conducted. In the former City of Moe, 5 new playgrounds have been built, two since local government amalgamations. New equipment has been installed in 3-4 playgrounds, and obsolete or dangerous equipment removed as required. A maintenance schedule was also established. The City of Morwell implemented its already existing strategy which required a playground to be located within 500 metres of every household.

In December 1994, the La Trobe Shire was formed by the amalgamation of the four municipalities covering the program region. One of the key players in the Playground Working Group moved interstate early in 1995, which in combination with the local government changes, contributed to the demise of this working group. However, since the formation of the new Shire, over $100,000 has been expended on tan bark undersurfacing for municipal playgrounds. Two formal written reports on playground safety have been produced bi-annually since 1994, and a maintenance crew conducts monthly playground audits using tick box check lists.

Other playgrounds: The program has enabled local parents to direct their concerns regarding playground equipment and design in play areas of a restaurant chain to the responsible person. As a result, two of these playgrounds have been completely rebuilt including the upgrade of undersurfacing.

4.3.4 Outcome measures

Emergency department presentations (poisson regression): A significant decrease in unintentional playground injury emergency department presentations was observed (0=0.001), in contrast with a non significant decrease in untargeted unintentional injury (p=0.08). A decrease was also observed for playground equipment related injury, although of borderline significance (p=0.051) (Appendix 4).

Emergency department presentations (logistic regression): The decreasing trend in unintentional playground injury emergency department presentation rates was significantly different to that

LATROBE VALLEY BEITER HEALTH PROJECT 23 observed for untargeted unintentional injury, among 5-14, 15-24, and 25-64 year olds (Appendix 5). The trend was slightly upward and not significant among 0-4 year olds and those over 65 years (Appendix 5). A downward trend in playground equipment related injury was observed among 5• 14, 15-24 and 25-64 year olds, although not significant (Appendix 5).

Injury frequencies adjusted for capture rates, age group crude rates and age standardised rates are tabulated in Appendix 6

1800 •.. -:*-other '" --~------~ ------""- Cl) :------___ equipplaygnd ---- c.- 1600 - --.- playgnd ------.! 1400 ca•.. c. ~ 0 1200 Cl) c. 0 1000 ~o.! ca"'0 - 800 ~OCO 600 ••ca• en 400 QCl) 200 4( o 1991/92 1992/93 1993/94 1994/95 1995/96

Year

Figure 2 Age standardised unintentional playground and playground equipment injuries, emergency department presentations (including those admitted), LRH 1991/92-1995/96. Other unintentional excludes program targeted injury, road and work related injuries.

4.4 SPORTS INJURY PREVENTION

4.4.1 Aims and objectives

Aim To reduce the incidence and severity of sports injuries in the Latrobe Valley. Issues chosen will be those identified through the VISS data collection in the Latrobe Valley

Objectives • to implement a comprehensive sports injury control program, to publicise risks associated with athletic activity and the necessity for conditioning programs

• to bring together relevant representatives to provide advice and assistance in reducing the injuries targeted

• to run an educational and consultative process throughout the Latrobe Valley concerning sports injuries

• to assess the nature and frequency of these injuries

24 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 4.4.2 Process measures

Courses: The Australian Rules Football Level 1 Coaching Courses in the area now include injury prevention as part of the course (2 hours in a 10 hour course), due to the activities of the LVBH injury prevention program. The Level 1 Courses are held annually and have approximately 70 participants in each course. The Australian Rules Football Level 2 Coaching Courses are conducted by a number of different presenters in the Latrobe Valley/Gippsland area with approximately 35 participants in each course. The program has been successful in supporting one presenter to include detailed sports injury data and prevention strategies as a regular feature of his coaching course. In addition, the Latrobe Valley Football League Trainers Program has incorporated injury data and recommendations for prevention on a permanent basis since July 1993. This Program is run annually with approximately 40-50 attendants at each session. In summary, during the evaluation period approximately 365 coaches and trainers have been exposed to injury prevention material in training courses.

Junior Sports Injury Prevention Promotion Night: This event was held in March 1994 by the program and was attended by approximately 70 people. Coaching, rule modification, and safety equipment grants were promoted on the night, with a presentation by Rod Austin, the State Coaching Director of the Victorian State Football League.

Sports injury prevention displays: A summary of these is found in Table 13.

Table 13: Sports injury prevention displays, Latrobe Valley Better Health Injury Prevention Program 1992-1996.

Year Location/event Estimated number attending 1993 Australian Sports Trainers Seminar 40-50 1994 State Junior Soccer Competition 200 1994 Recreational opportunities for low income people event 50 1994 Sports injury seminar 70+ 1994 Vic Fit Fitness Trainers Seminar 40 1995 Best and Fairest Awards 150

1995 Grand Final (function room) 200 1995/96 Gippsland League Football season launch 120 TOTAL 510-880+

Health promotion opportunities: These have been provided by the program for key events in the football calendar including the vote count, the media night, and the grand final. A naming rights sponsorship from Vic Health for the 1995/96 Gippsland Latrobe Football League season resulted in the slogan "Play safe sport" being widely promoted during this season. The slogan is associated with messages relating to sports injury prevention and decreased alcohol intake. Through these messages attention was drawn to player preparation (warm up and cool down), coach accreditation, and codes of conduct for players, supporters and clubs. Nine participating clubs were also required to provide low alcohol alternatives and dry areas at club venues. Maintenance of these activities

LATROBE VALLEY BETTER HEALTH PROJECT 25 within these 9 clubs is not certain, however the Morwell Football League has entered into a contract with the Australian Drug Foundation thereby maintaining these activities.

During April-June 1994, the program organised a series of television advertisements on sports injury prevention at the rate of three per day. There was no charge to the program for these advertisements.

Resources distributed: Posters promoting specific cricket safety messages, produced by Mercantile Mutual and the Victorian Dental Association, were distributed by the Gippsland Sports Assembly for the 1995/96 season.

4.4.3 Impact measures

Prevention knowledge: There was no significant difference in the pre- and post-intervention surveys in the proportion of respondents able to list ways to prevent sports injury (72.8%, 72.5%, p=0.22).

Protective equipment: The use of protective equipment for sports has been widely promoted by the program. In conjunction with Victoria University, the program participated in a trial of helmets for under age Australian Rules Football. One under 10 years and one under 12 years team in a Morwell club trialed the helmets and their injury results were compared with other teams not wearing the helmets. As a result of the trial, all teams in this club are now wearing helmets. The associated publicity and helmet availability has created a waiting list to play with the club. Consequently, at least three other clubs (one each in Churchill, Yinnar and Morwell) now have helmets for their under 10 and 12 year teams, in order to attract players.

The availability of relatively inexpensive mouth guards from the Latrobe Regional Hospital Dental Clinic has been promoted. Data from the Clinic showed that from 1 May 1994-30 April 1995, 46 mouth guards were provided, and from 1 May 1995 to 31 October 1996, 145 mouth guards were provided. No data were available prior to May 1994. Funding to the Clinic for this activity has been ceased and mouth guards are now fitted and sold for a fee of $45 each.

Six football clubs with predominantly junior players were also visited and fitted for mouthguards during training. Details of the number of mouthguards actually supplied via this mechanism, is however, uncertain.

Modified rules: A survey of junior football clubs by the members of the Sports Injury Working Party, early in 1993 showed that most clubs already used modified rules for their under 10 teams, with some clubs implementing these rules for their under 8 and under 12 teams. However, there was some variation in the version of modified rules implemented.

4.4.4 Outcome measures

Self reported injury: There was a significant increase in the proportion of injuries reported in the telephone surveys as occurring during a sporting activity during a two week reference period (29.1%,43.9%, p=0.02).

Emergency department presentations (poisson regression): A decrease in unintentional sport injury emergency department presentations was observed, although this was not significant (p=0.5) (Appendix 4). There has been a decrease in the frequency of admission for football injury, a primary focus of the sports injury prevention component, during the last two years of the program. during

26 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 1993/94, football injuries accounted for 50% of total sports injury admissions, compared with 28% for the 1995/96 year.

Emergency department presentations (logistic regression): A downward trend in unintentional sport injury emergency department presentation rates was observed for 15-24 and 25-64 year olds. The decreasing trend was significantly different to that observed for untargeted unintentional injury among 15-24 year olds only (Appendix 5). The trend was slightly upward for all other age groups and was significantly different to that observed for untargeted unintentional injury only for those 65 years and over. The effect in this age group is likely to be due to year to year variation in the small numerator (Appendix 6).

Injury frequencies adjusted for capture rates, age group crude rates and age standardised rates are tabulated in Appendix 6.

1800 1600 ~ ------.------1400 ~ ------.------1200

1:400 r::::::l:------•-=[:::::::::::::: ::: 200 ~ ------.------

O. 1991/92 1992/93 1993/94 1994/95 1995/96 Year

Figure 3 Age standardised unintentional sports injury, emergency department presentations (including those admitled), LRH 1991/92-1995/96. Other unintentional excludes program targeted injury, road and work related injuries.

Insurance and sport tribunal data: The Gippsland Latrobe Football League has reported a reduced number of medical insurance claims in 1996, compared to 1995. In 1996, member clubs submitted 44 claims for injuries costing $3995, whereas in 1995, 79 claims costing $13,059 were submitted. Loss of income insurance claims fell from $42,980 in 1995 to $28,758 in 1996. The Tribunal sat on 30 occasions in 1995 to hear 57 reports compared with 12 in 1996 to hear 24 reports, indicating a reduction in misdemeanours during football games.

4.5 ALCOHOL MISUSE

The Youth and Alcohol Action Plan has been implemented in the three main population centres by the Police Community Consultation Committees (PCCC). These groups are alliances of relevant individuals and organisations in each of the three towns. The LVBH injury prevention program officer is a major player in each group and has initiated considerable action in this area. The program officer is also a member of the Q district regional PCCC.

LATROBE VALLEY BETIER HEALTH PROJECT 27 4.5.1 Aim and objectives

Aim To reduce the harm associated with alcohol misuse by young people

Objectives • to promote awareness and understanding of youth alcohol issues

• to establish community-based Youth Alcohol Working Parties in the cities of Moe, Morwell, and Shire of Traralgon, with membership consisting of a range of groups such as young people, youth workers and community representatives drawn from the local Council, parents, schools, and other community groups

• to provide information regarding attitudinal, behavioural, social and environmental variables affecting the use of alcohol

• to assist locally-based Youth Alcohol Working Parties to identify factors which foster alcohol misuse by young people in their own town

• to assist locally-based Youth Alcohol Working Parties to address these factors via the development and implementation of action plans

4.5.2 Process measures

Non-alcoholic cocktail events: The LVBH injury prevention program has initiated and promoted the idea of non-alcoholic cocktails as an alternative to alcohol for young people in the area. Anecdotal evidence from the former City of Traralgon Youth Development Officer indicates that this idea came from the program officer and would not have been taken up if it had not been promoted by the Program. These cocktails have been widely promoted during at least 20 major events. Approximately 1,900 people (many of them under 25 years of age) have attended these events, such as the Battle of the Bands, where the cocktails have been available and promoted. As a direct result of these activities, there is now one local business, Free Spirit Cocktails, which supplies these cocktails to functions, and one local night club has made non-alcoholic cocktails available for patrons. Hospitality 2000, a national company which commenced business in the Latrobe Valley in 1993, began providing non alcoholic cocktails at their events from early in 1994. Skill Share provides training in making non alcoholic cocktails through Hospitality 2000, and from May 1995, 37 participants have completed this training.

Youth drop in centres: As a result of the program officer working with other local groups, three youth drop in centres have been established, one each in Churchill, Boolarra, and Moe. These are held on various nights with attendance ranging from 20-60 and an age range of 12-25. Also 3 full time staff and 6 casual staff are involved in these centres with an age range of 24-52.

Responsible Serving of Alcohol Courses: A Liquor Licensing Commission Responsible Serving of Alcohol Course was run by the program in conjunction with the Gippsland Community Road Safety Council, in April 1993. There were 35 participants, all of whom were employees of local hotels and clubs, representing at least 10 venues.

28 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE The Bar and Waiter Course, run jointly by La Trobe Shire SkillShare and Hospitality 2000, includes a component on the responsible serving of alcohol, due to an industry requirement. In 1995, 37 participants completed this course.

Latrobe Valley Liquor Industry Accord: This code of conduct for clubs and hotels was introduced by the program officer to the PCCC in 1993, and was then taken up by the Police. All licensed premises in the area have agreed to this accord which came into effect in September 1994. Under the accord, participating premises are given a certificate (which is being advertised by some establishments), agree to a standard cover charge, standard prices for drinks, no pass outs, no under age drinking, and encouraging employees to complete a Responsible Serving of Alcohol Course.

Participants in the Accord attend bimonthly meetings to discuss and co-ordinate strategies. Liquor retail outlet operators are now joining the Accord. The police are also requesting sporting clubs from the area to attend the Accord meetings in an attempt to address the issue of alcohol consumption in association with sporting events. As a result of the Play Safe Sport Vic Health sponsorship, anecdotal evidence suggests that 10% of football clubs in the area have established dry areas and provide low alcohol alternatives at their venues.

Drink Safe: This campaign was a joint initiative of a number of organisations including the La Trobe Safe Communities Program, Victoria Police, Central Gippsland Alcohol and Drug Service, the Liquor Licensing Commission and the Community Road Safety Council. The Drink Safe program aims to promote safe levels of alcohol use through the demonstration at local venues, of the lower levels of intoxication achieved by the consumption of light alcohol, compared to regular alcohol.

The Drink Safe program is implemented by facilitators who run demonstrations at local hotels and clubs where alcohol is consumed. The demonstrations involve participation by volunteers from the patrons present at the time. One group of patrons consumes heavy beer and a second group consumes light beer over a two hour period. Blood alcohol levels are then measured every 40 minutes, and recorded on a board with the progressive number of drinks consumed. The display of the results in this way serves to demonstrate to all patrons present the effects of consuming light compared to heavy beer.

A pilot Drink Safe campaign was conducted in nine Latrobe Valley venues over the period October 1994-March 1995. A total of71 patrons aged between 31 and 50 years participated directly in the demonstrations. The evaluation was conducted by the Monash University Centre for Police and Justice Studies (Berends and Veno, 1996). Participating patrons (71), and 49 observing patrons completed a questionnaire at the start of the demonstration, and 57% (32) were followed up in a telephone interview conducted 9 months after the demonstration. A statistically significant proportion of respondents reported that they had improved their knowledge about alcohol consumption as a result of their participation. Self reported drinking behaviour had changed following participation, with 53% of patrons reporting that they drink less often, and 94% reporting reduced amounts of alcohol consumed (Berends and Veno, 1996).

In the absence of a comparison group, it is difficult to conclude that these effects were due to the Drink Safe program, since a number of other initiatives were operating in the Latrobe Valley during this period. Other factors such as the economy, may also have had an influence. Further, it is difficult to assess the impact of the program on patrons who did not become directly involved as participants or observers interested enough to complete the questionnaire. The campaign was well received by the majority of venue managers, operators, staff and patrons, and resulted in an

LATROBE VALLEY BETfER HEALTH PROJECT 29 improved public relations image for the police who participated at each demonstration. Since the pilot sessions a further 6 Drink Safe campaigns have been conducted.

The Gippsland Anti-violence Strategy, which incorporates a number of the program objectives on alcohol action, such as Drink Safe, alcohol free cocktails and youth drop in centres, has recently attracted $360,000 funding for a period of three years through the Department of Justice. Venue safety audits have been conducted in Moe and Traralgon by the PCCC as part of the anti-violence strategy.

Local legislative changes: As a result of action by the Traralgon PCCC, local by-laws prohibiting alcohol consumption in public places in Traralgon were enacted in 1993/94. Similar laws were subsequently introduced for the Morwell business district. As a result of shire restructure in 1995, all three major centres, Moe, Morwell and Traralgon passed by-laws banning alcohol consumption in the central business district.

4.5.3 Impact measures

Alcohol consumption: During the years of the program, litres of alcohol (excluding light alcohol products) purchased by retail liquor outlets in the program region have decreased marginally (0.15%), while light alcohol purchases have increased by 16.45%. In comparison, in country Victoria purchase of both regular and light alcohol products have decreased by 4.77% (Table 14). It should be noted that these figures represent the litres of alcohol purchased by the outlets, not litres sold to the public. In some instances, increases may be the result of re-stocking of products which may then be sold over an extended period.

Table 14: Percentage change in alcohol sales (litres) La Trobe Shire and Country Victoria 1991-1995

1991• 1992• 1993• 1994• 1992* 1993 1994 1995 Alcohol

(excluding light product) La Trobe Shire -9.89 -1.25 1.11 -0.01

Country Victoria -8.80 -8.67 2.16 1.01 Light alcohol La Trobe Shire -0.08 7.14 -12.39 21.70

Country Victoria -6.05 -6.87 -1.30 3.40

*pre-program period

4.5.4 Outcome measures

Drunk and disorderly arrests: There were non significant increases in the rates of arrest for being drunk and disorderly for both the 15-24 year age group (targeted with alcohol misuse programs) and the over 25 year age group (Figure 4, Table 15). Anecdotal evidence (Appendix 7) indicates that there was a significant reduction in arrests for assaults in and around licensed premises in Traralgon between December 1994 and 1995. Wilful damages charges are also reported to be reduced.

30 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Q. 4500 8. 4000 ~------• og 3500 ~------o 3000 : 2500 ~ ------!. 2000 ~------• ::::;::2~[~~~~~~~ ! 1500 ~ ------• ~ 1000 ~ ------• 'g•.. 500 U 0 1991/92 1992/93 1993/94 1994/95 1995/96 Year

Figure 4 Drunk and disorderly arrest rates, Latrobe Valley Better Health Injury Prevention Program Region, 1991/92-1995/96

Table 15: PoissonSignificanceincreasingStandardnotP-value0.1470.0820.0430.044significantTrendregressionslope+0.075+0.064Slopefor analysis, drunk and disorderly arrest rates, Latrobe Valley error (slope) Better Health Injury Prevention Program Region, 1991/92-1995/96 25 years + 15-24 years Age group

Motor vehicle crashes involving alcohol: There were significant decreases in the age specific crude rates of motor vehicle crashes during high alcohol times in both the program and comparison region of small rural centres (Table 16). In both regions, the decreases occurred during the pre• program years (Figure 5).

Table 16: Poisson regression analysis, high alcohol time serious motor vehicle crash crude rates 0-24 yean, Latrobe Valley Better Health Injury Prevention Program Region and Victorian Small Rural Centres, 1987/88-1995/96

Area Slope Standard error P-value for Trend Significance (slope) slope

Latrobe Valley -0.097 0.034 <0.0044 decreasing significant

Small Rural Centres -0.111 0.025 <0.0001 decreasing significant

LATROBE VALLEY BEITER HEALTH PROJECT 31 Q.o 160 I oQ. 140 ------,-+- programregion g 120 ------,_comparison region,- - - 100 g.•.. :; 80 Q. 60 oS l! 40 _ Q) "Cl 20 _ ::s U 0 1987/88 1989/90 1991/92 1993/94 1995/9 Year

Figure 5 High alcohol time serious motor vehicle crash crude age specific rates for 0-24 year age group, Latrobe Valley program region and Victorian small rural centres (comparison region), 1987/88-1995/96

Emergency department presentations for intentional injury (Poisson regression): A significant decrease in emergency department presentations for intentional injury inflicted by others was observed (p=0.035) for 10-24 year olds, in contrast with a non significant decrease for those over 25 years (p=0.69) (Appendix 4).

Emergency department presentations for intentional injury (logistic regression): The decreasing trend in emergency department presentation rates for intentional injury inflicted by others for 10-24 year olds was significantly different to that observed for those over 25 years of age (Appendix 5).

Injury frequencies adjusted for capture rates, age group crude rates and age standardised rates are tabulated in Appendix. 6.

1600 g. 1400 : 1200 -+-1~24~,------• 1000 g ___ 25+~ .•..g 800 :; 600 -: 400 ~ 200 o 1991/92 1992/93 1993/94 1994/95 1995/96 Year

Figure 6 Intentional injury inflicted by others, emergency department presentations (including those admitted), LRH 1991/92-1995/96.

4.6 STRATEGIC LINKS WITH LOCAL ORGANISATIONS

The summary below is based on the 4 key informant interviews conducted to determine the extent to which the project had been successful in forming strategic links with local organisations. Transcripts from the interviews can be found in Appendix 7.

32 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE The influence of the LVBH injury prevention program has resulted in the establishment of Working Parties, which in turn, initiated appropriate goals and promotional activities, giving a real focus and direction. While it was acknowledged that previous strategies or actions had been developed, the involvement of the program officer brought fresh ideas, facilitated links, and increased the rate of implementation. Links were established between other programs in the community and the injury prevention program, a key feature of the successful Swedish programs. The collaborative approach of the program officer was perceived to be a worthwhile and positive action in the process of establishing a safe community.

The LVBH injury prevention program officer was well accepted and acknowledged by the local organisations as a driving force providing guidance and suggestions, without imposing or dictating ideas. The program coordinator was also able to access groups and individuals that the local organisations sometimes were not able to directly approach. The coordinator was also able to disseminate up to date information regarding safer community activities around Australia and the world, for which local organisations were grateful, as they would under normal circumstances not receive this information.

Community education was seen as a major part of the role played by the injury prevention program. The program officer was seen to have raised the community awareness through presentations, resource distribution and media coverage. The local organisations consulted felt that with the assistance and drive of the program officer, injuries had been reduced and that the community was a safer place. Long term implementation of projects had also been achieved. The safety image and awareness within some local organisations has also helped to increase participation rates and portray a positive image. The awareness of safety issues in the community is perceived to be much broader now because of the work of the LVBH injury prevention program.

It is clear from the interviews that the program has built strategic partnerships with local organisations and that these partnerships have resulted in an increased emphasis on safety by the organisations themselves. The program also facilitated interaction between agencies and individuals who had previously not interacted or coordinated their activities. However, given the indications that the program officer was a critical driving force in achieving these outcomes, it is unclear the extent to which safety would continue to be pursued by local organisations without continual support and guidance.

4.7 INJURY OUTCOME

4.7.1 Self reported injury (telephone survey)

There was a non significant decrease in the rate of self reported injuries recorded in the telephone surveys (62.7/1000 persons, 48.2/1000 persons, p=O.19). The proportion of injuries requiring medical or allied health attention increased, although this was not significant (24.5%, 31.9%, p=O.42)

There was a non-significant decrease in the proportion of injuries reported as occurring in a residential location during the two week reference period (37.9%, 28.1%, p=0.25). There was a significant increase in the proportion of injuries reported as occurring during a sporting activity (29.1 %,43.9%, p=O.02).

4.7.2 Emergency department presentations

The age standardised rate per 100,000 persons for emergency department presentations for all targeted unintentional injury fell from 6593.74 in the first program year to 4820.91 in the final evaluation year. This decrease was significant in the Poisson regression analysis (p=0.017), in contrast to a non-significant decrease observed for non-targeted injury (p=0.08) (Appendix 4).

In the logistic regression analysis, the decreasing trend in all targeted unintentional injury was significantly different to that observed for untargeted unintentional injury, among all age groups tested (0-4,5-14, 15-24, 25-64, 65+ years) (Appendix 5).

LATROBE VALLEY BEITER HEALTH PROJECT 33 ~ 7000 ~ Q. ~ 6000

•l'Cl "~ Q.0 ~ Q. .!QO "0~O 400050003000 ------_all other------targettecl • ------~ ~ ~ ~ l'Cl • -+- ,,0 I---- CO 2000 ~ ------~ ------l'Cl •••• en ~ 1000 ~ ~ _ l:D c( o 1991/92 1992/93 1993/94 1994/95 1995/96 Year

Figure 7 Age standardised unintentional emergency department presentations (including those admitted), LRH 1991/92-1995/96. All targeted injury includes home, playground and sport injury. Other excludes program targeted injury, road and work related injuries.

There were decreases in each of the targeted unintentional injury categories, which were significant for:

• home injuries among all age groups except those 65 years and over (Section 4.2.4, Appendices 4 & 5) • playground injuries among 5-14, 15-24, and 25-64 year olds (Section 4.3.4, Appendices 4 & 5) • sport injury among 15-24 year olds only (Section 4.4.4, Appendices 4 & 5)

The reductions were of borderline significance in the Poisson regression for playground equipment injury emergency department presentations (Section 4.3.4, Appendix 4).

There were also significant reductions in intentional injury emergency department presentations for the 10• 24 year age group compared with those 25 years and over (Section 4.5.4, Appendices 4 & 5).

4.8 COST BENEFIT ESTIMATES

The program received $246,988 in grants over the current evaluation period. An estimated 908 injuries were prevented, beyond the background reductions observed in non-targeted injury, assuming that the rate for targeted injury would have remained at the 1991/92 level in the absence of the program. The direct program costs per injury saved were therefore approximately $272. This does not take into account the considerable in kind contribution of personnel and resources made by a range of other local organisations.

4.9 INSTITUTIONALISATIONANDSUSTAINABILITY

Sustainability, in the context of health programs, refers to the ability to provide ongoing control of the health problem. This can be accomplished in the field of injury prevention in a number of ways including: design and permanent environmental changes; policy and legislative changes; and institutionalisation (Day, 1995). Institutionalisation is an important concept as it refers to the 'long term viability and integration of a new program within an organisation' (Stekler and Goodman, 1989). This could apply to a complete program or to certain elements of a program. Institutionalisation results in a longer term impact on the health issue, often a pre-requisite for meaningful assessment of outcomes. The failure to institutionalise, where this is appropriate, can result in wasted resources and the loss of community confidence and trust (Stekler and Goodman, 1989).

34 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 4.9.1 Design and permanent environmental changes

Playground Some schools have attended to unsuitable playground equipment and surrounds. In addition, one school reported that safety and injury prevention would become one of the school's priorities under the Schools of the Future Program in 1994.

New municipal playgrounds incorporating safety features have been constructed, and hazardous playground equipment removed. Undersurfacing has been upgraded throughout the new municipality, and monthly audits are routinely conducted using tick box check lists.

4.9.2 Policy and legislative changes

Low alcohol drink availability atfootball games Nine participating clubs agreed to provide low alcohol alternatives and dry areas at club venues. Maintenance of these activities within these 9 clubs is not certain, however the Morwell Football League has entered into a contract with the Australian Drug Foundation, maintaining these activities.

Helmet use for Ul0-12 footballers In conjunction with Victoria University, the program participated in a trial of helmets for under age Australian Rules Football. As a result of the trial, all teams in this club are now wearing helmets. The associated publicity and helmet availability has created a waiting list to play with the club. Consequently, at least three other clubs (one each in Churchill, Yinnar and Morwell) now have helmets for their under 10 and 12 year teams, in order to attract players.

La Trobe Valley Liquor Industry Accord All licensed premises in the area have agreed to this accord which came into effect in September 1994. Under the accord, participating premises are given a certificate (which is being advertised by some establishments), agree to a standard cover charge, standard prices for drinks, no pass outs, no under age drinking, and encouraging employees to complete a Responsible Serving of Alcohol Course.

Local Legislative changes Local by-laws which prohibit alcohol consumption in public places in central business districts of Moo, Morwell and Traralgon, have been enacted.

Municipal Public Health Plan Safety issues are now included in the La Trobe Municipal Public Health Plan, and the Gippsland Regional Public Health Plan.

Codes of conduct - Play Safe Sport Codes of conduct for sport players, supporters and clubs have been developed and adopted.

4.9.3 Institutionalisation

Home safety trainingfor professionals La Trobe Shire and Silver Circle home care staff, in addition to the La Trobe Shire home maintenance staff, receive training sessions in falls prevention. Similar training has also been incorporated into the La Trobe Shire Volunteer Training Program.

LA TROBE V ALLEY BETIER HEALTH PROJECT 35 The Falls Prevention Program training package has been included in the curriculum of three TAFE courses at Newborough: Residential and Community Services, Certificate of Home Care and Advanced Certificate of Home Care.

School safety presentations to Monash University Gippsland Campus Primary Education classes School safety (playground and sports), presented by the program officer, has been a feature of the Monash University Gippsland Campus Bachelor of Education (Primary) course since 1992.

Australian Rules Football coaching course Levell and 2 inclusion of injury prevention components The Australian Rules Football Level 1 Coaching Courses in the area now include injury prevention as part of the course (2 hours in a 10 hour course), due to the activities of the injury prevention program. The Level 1 Courses are held annually. The Australian Rules Football Level 2 Coaching Courses are conducted by a number of different presenters in the Latrobe Valley/Gippsland. The program officer has been successful in supporting one presenter to include detailed sports injury data and prevention strategies as a regular feature of his coaching course.

Australian Rules Football trainers program injury prevention component The Latrobe Valley Football League Trainers Program has incorporated injury data and recommendations for prevention on a permanent basis since July 1993.

Responsible serving of alcohol La Trobe Shire Skillshare has adopted responsible serving of alcohol courses as part of their program. The Bar and Waiter Course, run jointly by La Trobe Shire SkillShare and Hospitality 2000, includes a component on the responsible serving of alcohol, due to an industry requirement.

Permanent safety displays at La Trobe Regional Hospital This has been in place in the emergency department reception area at the Traralgon campus since November 1995. Two out of the three consortia tendering for the new La Trobe hospital have agreed to include the safety display in their proposal, after discussions with the LVBH injury prevention program officer.

Non-alcoholic cocktail products As a direct result of the Program activities, there is now one local business, Free Spirit Cocktails, which supplies these cocktails to functions, and one local night club has made non-alcoholic cocktails available for patrons. Hospitality 2000, a national company which commenced business in the Latrobe Valley in 1993, began providing non alcoholic cocktails at their events from early in 1994. Further, the preparation of non• alcoholic cocktails is included in their training programs. Skill Share also provides training in making non alcoholic cocktails.

Youth drop in centres As a result of program officer working with other local groups, three youth drop in centres have been established, one each in Churchill, Boolara and Moe. These are held on various nights with attendance ranges from 20-60 and an age range of 12-25. Also, 3 full time staff and 6 casual staff are involved in these centres, with an age range of 24-52. The future of these centres is dependent on funding from sources outside the program.

'Drink safe' Further drink safe campaigns are likely to operate under the Gippsland anti-violence strategy, which has been funded for three years.

36 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Safety and sport The opportunity to promote the sports safety message has enabled the Gippsland Latrobe Football League to present a very professional face to the community. It helped to develop a good public image, presenting football as family entertainment and a game that cares for the safety of its players, especially the young players. It is highly likely, therefore, that safety within sport will remain a key focus for this organisation

Institutionalisation of programs within local government The short term future of the program has been secured by an agreement between the Victorian Health Promotion Foundation and the new La Trobe Shire. Under this agreement, the Foundation will gradually reduce its funding over the next three years, while funding by the Shire, and local industry, will gradually increase. The program officer position is now a local government appointment and the program will operate within local government.

In 1996, the program was accredited as a Safe Community by the World Health Organisation. As a result, the La Trobe Shire entered into an agreement to continue to support safe community principles in the area.

LATROBE V ALLEY BETTER HEALTH PROJECT 37 38 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 5. DISCUSSION AND RECOMMENDATIONS

5.1 EVALUATION DESIGN AND METHODS

This evaluation has a number of limitations, which is not unique in the area of community-based program evaluation (Langley and Alsop, 1996, Sanson-Fisher et aI., 1996, Ozanne-Smith, 1997). The community was self-selected and there was no discrete comparison community in which a comparable series of measurements were made, thereby threatening the internal validity of the evaluation study. Measurement of the outcome was at the level of the individual rather than at community level.

The absence of a consistent prospective system for recording process measures has probably resulted in an under-estimate of the extent of implementation. An established and consistently applied method for recording process measures is recommended, not only for evaluation purposes but as an historical record of all program activities.

The relatively poor response rate in the post-intervention telephone survey (55.5%) raises the issue of bias in these results. There was no data collected from the non-responders. However, the demographic profile of the pre and post-intervention survey respondents provides some insight into potential biases.

The higher proportions of self-nominated country dwelling respondents, and of male respondents, may have biased the results toward the null hypothesis in that country dwelling households may be less likely to attend public events where the program safety messages were disseminated and less likely to be able to access a range of shops to purchase safety items. Male respondents may be less likely to take up safety messages and perhaps less likely to remember household safety purchases.

Higher proportions of male respondents in the post-intervention survey may have biased the self-reported injury results in that males may be less likely to remember these events, assuming that the females in the household generally administer more of the first aid. This may have been countered by the higher number of children and the higher proportions of older children (10-17 years), which would have the effect of increasing the number of injuries reportable in the post intervention survey.

The absence of suitable emergency department data for comparison purposes limits conclusions which can be drawn about the extent to which the program contributed to the observed injury reductions. An alternative strategy of using state wide hospital admissions data to provide some comparison was frustrated, apparently by changes to health care system funding. Hospital admissions data utility was compromised to the extent that statistical modelling was of little use in determining program impact in comparison to other similar regions in Victoria. This is an issue of considerable significance for injury research and prevention in Victoria, creating difficulties in monitoring trends over time.

The fit of 12 out of the 25 statistical models of the emergency department data was not ideal, there being a larger than expected amount of variation unexplained by the models (Appendix 5). There were a limited number of variables to include in the models, and it is apparent that additional unknown factors were influencing the emergency department injury data. Despite this, there was still a demonstrable effect of the program. It is possible that the unknown factors may remove some of this effect, once identified and included in the models. However, it would be unlikely that these factors would remove all of the program effect observed.

The evaluation was not able to take account of the potential impact of unemployment, social instability, uncertainty regarding the future of the Latrobe Regional Hospital, or organisational restructure and downsizing. The Latrobe Valley was plagued by all these factors during the evaluation period. There is no doubt that these factors would have affected program implementation. It is possible that more extensive implementation may have been achieved during a less disruptive period.

LATROBE VALLEY BETIER HEALTH PROJECT 39 Although less than ideal in some aspects, the evaluation design and methods have been strengthened by a number of features. The inclusion of process, impact and outcome measures facilitates the observation of potential links between program activities, changes in injury risk and protective factors, and injury outcomes, in addition to providing some insight into the mechanisms by which community based programs effect a result. The combination of qualitative and quantitative methods added another dimension, enhancing the evaluation results.

The Latrobe Valley Better Health Project region is a well defined geographic area, reducing the likelihood of contamination from neighbouring programs and activities and conversely confining the influence of the program. Population data were available from the Australian Bureau of Statistics for most of the required years, and reliable estimates using official growth rates were made for the last two program years.

One of the strongest features of the evaluation is the prospective injury surveillance system operated at the Latrobe Regional Hospital by the Victorian Injury Surveillance System (VISS). The data collection method remained unchanged for the five year period and there was continuity of key staff including the emergency department director and the data processor. Regular audits identified the capture rates for both campuses of the hospital, allowing adjustment for variations in capture. Standards implemented by VISS ensured that the collection included at least 85% of the presentations and 100% of the admissions. The coding system used by VISS allowed disaggregation of the data into the same categories targeted by the program. Age standardisation of injury rates adjusted for population changes during the course of the program, an important feature since the Latrobe Valley has undergone some characteristic demographic changes during the program period.

The availability of additional resources and expertise, through a National Health and Medical Research Council Public Health Fellowship, added considerable resources to the program evaluation budget, allowing more extensive analysis than would otherwise have been possible.

5.2 ATTAINMENTOF PROGRAM OBJECTIVES

The majority of program objectives, that were evaluated, were met to some extent (Appendix 8). A range of promotional, educational and awareness raising activities were undertaken in the home, sports and playground injury areas. These activities appeared to result in an increase in community awareness, with significant changes in some knowledge measures, particularly those relating to home injury prevention. Unsafe playground equipment was removed, and playground undersurfacing was upgraded in some municipal and private playgrounds.

The use of safety devices and equipment was increased for some sporting activities, particularly football. The demand for helmet use in junior football increased, as did the availability of mouthguards. Youth alcohol working parties were established in collaboration with the Police Community Consultative Committees. Through these working parties, information was provided to key players and the community regarding factors affecting alcohol use and local factors were identified. A range of initiatives were undertaken including increasing the acceptance and availability of non/low alcohol alternatives, responsible serving of alcohol, widespread acceptance of a code of conduct for clubs and hotels, and changes in local legislation prohibiting consumption of alcohol in central business districts.

There were examples where the program objectives were expanded as opportunities arose. For example, an older persons falls prevention component was undertaken in collaboration with a number of other organisations when specific additional funding became available through the Department of Human

40 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Services. Similarly, the youth alcohol component has expanded the program activities into violence prevention.

It should be noted however, that none of the stated program objectives extended to include quantitative targets. Therefore, while there is evidence that most objectives were met, there is no measure of the extent to which the objectives were met. Some objectives were met for a limited period of time eg., the Safety Features Display Home met one of the objectives of the home injury prevention component, but only for an 8 week period. Similarly, a permanent display of information on child safety has been secured at the Traralgon campus of Latrobe Regional Hospital. Public hospital services in the Latrobe Valley will soon be contracted to a private provider and a new hospital is currently being built on a different site. It is not yet clear whether the permanent display will be maintained in the new hospital.

The program certainly achieved the aims of utilising a community intervention approach, developing collaborative relationships with local organisations and achieving some structural and organisational change which has the potential to provide a cumulative benefit.

5.3 INJURYREDUCTIONS

Injury reductions were observed in both self-reported injury and emergency department presentation data for all of the three targeted unintentional injury categories. The reductions were statistically significant for home injury among all ages except those 65 years and over, playground injury among 5-14, 15-24, and 25• 64 year olds, and sport injury among 15-24 year olds. The reductions were of borderline significance for playground equipment injury emergency department presentations. There were also significant reductions in intentional injury emergency department presentations for the 10-24 year age group.

The decreases appear to be real. Changes in patient presentation patterns could account for the observed reduction, for example if injured residents were presenting to other health care providers such as general practitioners or other local hospitals. If this were the case, it would be expected to occur for non targeted injury as well as injury targeted by the program. There was, in fact, a decrease in non targeted injury. It was not significant and was considerably less than that for home and playground injury. A decrease in emergency department injury capture rates could also explain the observed decreased injury rates. However, capture rates were estimated regularly at both hospital campuses and the injury data adjusted accordingly.

The telephone surveys revealed that awareness of household safety features increased, as did knowledge about where to purchase safety items. There was no evidence though for any increases in knowledge about how to improve home safety, numbers of safety features per house, or the proportion of households having purchased safety items in the preceding 12 months. Consequently, if the significant reductions in home injury emergency department presentations are attributable to the program, the mechanism was behavioural, rather than environmental, modification. The potential for a bias towards the null hypothesis noted earlier may be relevant here.

The significant reduction in playground injury emergency department presentations was associated with the reduction of hazardous equipment in municipal playgrounds and improved maintenance schedules, factors which can be attributed to the program, at least in part. Reduced exposure could account for a lowered playground injury rate. However, in most instances the hazardous equipment was replaced, and in one former municipality the amount of playground equipment actually increased. Reduced exposure could

LATROBE VALLEY BETIER HEALTH PROJECT 41 therefore only explain the injury reductions if there was a decrease in playground use by the community, which is unlikely.

Changes in risk and protective factors for sports injury are more difficult to detect. There was no evidence for improved sports injury prevention knowledge in the community, although the baseline was relatively high with 73% of respondents in the pre-intervention surveyable to list ways of preventing sports injury. There were no measures made of the impact of sports injury prevention training provided for coaches and trainers. There was some evidence for a change in the culture of sports clubs, with an increased emphasis on safety being incorporated. There was also some evidence to suggest increased use of protective equipment, particularly in junior football. Although the reduction in sport injury emergency department presentations was not statistically significant, there is some evidence that the reduction could be attributed, at least in part, to program activities. The relatively late introduction of the sports interventions would reduce the likelihood of observing a significant effect on injury outcomes.

In summary, there is some evidence to suggest an association between program activities and the observed reductions in targeted unintentional injury emergency department presentations. This conclusion is supported by three additional observations:

• the reductions were significant in both statistical models in the two program areas in which activities were implemented for a longer period ie., home and playground

• the reductions were incremental from the first program year for home and playground injuries

• a small non-significant reduction was observed for non-targeted injury

It remains, however, that the lack of comparative injury data constrains the strength of the conclusions which can be drawn about the association of the program with the reduction in less severe injuries. A state wide or regional downward trend in emergency department presentation rates may have been occurring at the same time. The Department of Human Services has been actively supporting the implementation of the state injury prevention strategy during the program period. Availability of comparative emergency department data would facilitate further consideration of program outcome.

An association between program activities and any decrease in alcohol misuse by young people is more difficult to determine. Two injury categories known to be highly associated with alcohol, motor vehicle crashes and intentional injury by others (ie., assaults) were used as proxy outcome measures of alcohol misuse. There was no significant reduction in serious injury motor vehicle crashes in high alcohol hours in the program region compared to other rural areas of Victoria. This may be more due to changes in drinking and driving patterns among young people across Victoria, than due to changes in alcohol misuse. By contrast, there was a marked reduction in the rate of intentional injury by others among 10-24 year olds, compared to little change in the rate for those over 25 years. This is an encouraging result. Unfortunately, the measures of changes in alcohol misuse by young people were weak. Data on alcohol sales reflected sales to liquor outlets rather than sales to the public. Rates of arrest for drunk and disorderliness may be influenced by changes in policing policy. There is also the possibility that the increased arrest rate for drunk and disorderliness contributed to the reduction in intentional injury, with young people being arrested more frequently before arguments occurred or escalated to injurious conclusions.

5.4 COST EFFECTIVENESS OF COMMUNITY BASED INJURY PREVENTION

Assuming that the observed effects are completely due to the program, then the cost of preventing one emergency department presentation was $272. This is likely to be an under-estimate since it does not include the considerable in kind contribution of personnel and resources made by a range of other local organisations. Nor does it include the unpaid additional hours worked by the program officer.

42 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE There was insufficient data for pre-program years to detennine the likely injury rate trend if the program had not been implemented. This estimate was made assuming that the rate of injury would have remained constant in the absence of the program. The number of injuries prevented would therefore have been underestimated if the trend in targeted injuries were increasing, and over-estimated if the trend in targeted injuries was decreasing more rapidly in the absence of the program than that for untargeted injuries, which is unlikely.

The analysis of cost effectiveness has not yet been extended to estimate the cost of the injuries prevented. Direct costs of emergency department presentations vary according to injury type and severity. The cost of an emergency department presentation which does not require treatment beyond that provided at the initial visit has been estimated at $86.67 (Jackson et aI., 1995). This does not include pre-hospital treatment or diagnostic imaging, such as an X ray which has been costed at $76.73. Presentations which require subsequent review in either the emergency department or outpatients have been costed at $173.74 and $188.54 respectively (W. Watson, personal communication). Although these costs are less than the cost of one injury prevented, a comprehensive analysis using the treatment cost of injuries prevented, calculated by stratifying on the basis of treatment required, is necessary before drawing final conclusions regarding the cost benefit ratio. Costs incurred beyond the initial treatment should also be considered. For example, estimates of the average cost of hospitalised injury for the first three years are $6,511, and for non• hospitalised injury the cost is $1,200 (W. Watson, personal communication). It may also be the case that the benefits of the program are cumulative, while costs are greatest during the initial establishment phase. This being the case, then the cost benefit ratio could be expected to improve over the next three to four years.

5.5 PROGRAM SUSTAINABILITY

The analysis conducted to date indicated that a number of different aspects of the program have become incorporated into the "business" of other local agencies and organisations. The positioning of the program within local government has been achieved for the express purpose of ensuring sustainable action. The incorporation of safety issues in the La Trobe Municipal Public Health Plan, and the Gippsland Regional Public Health Plan are encouraging signs of a long tenn commitment to injury prevention at the localleveI. It remains to be seen whether this commitment will result in the allocation of sufficient resources for sustained action.

5.6 FUTUREDIRECTIONS

5.6.1 Latrobe Valley Better Health Injury Prevention Program

The program has been re-named La Trobe Safe Communities and incorporated into the local government structure, bringing new challenges and opportunities. There would be considerable merit in building on the increased levels of awareness, knowledge and training by increasing the emphasis on environmental, legislative and policy changes, particularly in the home and sports injury prevention components. Incentives to change home environments, and to,use protective equipment may be needed. Availability of and access to safety products and protective equipment may require improvement.

The incorporation of the program into local government provides the opportunity to examine all aspects of local government operations with a view to incorporating safety into routine activities and services. One obvious issue to pursue is the playground strategy of the newly fonned local government, ensuring that equipment safety and continuing maintenance is incorporated and implemented. Other issues which could be pursued include the incorporation of safety promotion and environmental change into processes such as building plan approvals and inspections, and home and community care services. The competitive council tendering process offers opportunities for safety to be incorporated into contracts as a key performance indicator. As a relatively large employer, the Council could be promoting the notion of 24 hour safety among its employees and contractors.

LATROBE VALLEY BETIER HEALTH PROJECT 43 5.6.2 Continuing evaluation of the Latrobe Valley Better Health Injury Prevention Program

Given the encouraging results of the evaluation to date. there is merit in continuing to monitor the impact of the ongoing injury prevention program. However. there would be little additional benefit in continuing with the current design. Further evaluation of this program must strengthen the conclusions which can be drawn about the association between program activities and injury outcome. It is imperative that a comparison community be identified on the basis of the following characteristics:

• availability of good quality emergency department injury data • minor proportion of La Trobe program residents treated in the comparison community • minimum possibility of contamination with program activities • similar injury hospitalisation rate to Latrobe Valley Measurements which should be made both in Latrobe Valley and in the comparison community include impact and outcome measures such as:

• emergency department presentation rates for injury • hospital admission rates for injury • self-reported injury rates obtained in a random household telephone survey in April 1998. and 2000 or 2001 • changes in knowledge. awareness and practice relating to safety determined in a random household telephone survey

Consideration should be given to increasing the number of households surveyed to increase the statistical power available for testing changes in self-reported injury. an important safeguard against unexpected changes in the health care system which may influence injury surveillance data. Other methods of short term injury surveillance at the community level may be considered. such as the use of an injury calendar for one month periods in a random sample of households. or periodic general practice injury surveillance.

A feasible system should be designed and utilised to document process measures of program implementation. If training continues to be a feature of the injury prevention program. then the impact of training programs on performance should also be determined. Institutionalisation of program components and activities into local government, and into other relevant local organisations. should be monitored and evaluated.

The continued availability of high quality emergency department injury surveillance data from the Latrobe Regional Hospital is critical. not only for continued evaluation. but also for program implementation. Local injury data has been a powerful motivating tool for the program. and a cornerstone of the evaluation. Retrospective emergency department injury data should also be collected for the comparison community to strengthen this current evaluation. A small feasibility study has been conducted at Warragul Hospital. which serves a nearby Gippsland community. with encouraging results. The frequency of injury presentation could be determined from the department records. and in most cases age. sex and discharge status were also recorded.

5.6.3 Future directions for community-based injury prevention program evaluation

It would be highly desirable to extend the cost benefit analysis of the Latrobe Valley program. Regardless of the size of injury reductions achievable with this approach. the investment in such programs should be justifiable at least in terms of financial rewards. Such a study would provide significant results for the field of community based injury prevention nationally and internationally. It would be possible to stratify predicted injury reductions by treatment required. and possibly by body part injured. to allow derivation of cost benefit ratios. A current MUARC study of the cost of injury in Victoria will provide standard estimates of the direct costs of treating different injury types. which could then be applied to the predicted injuries prevented in the Latrobe Valley program.

44 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Further evaluations of the type reported here will provide reducing returns. The limitations of the quasi• experimental design, even if a comparison community is included, are significant. Future developments should focus on controlled trials of multiple communities randomly assigned to treatment and control groups, consisting of more than one community. The analysis would then be conducted at the level of the community rather than the individual. The financial and logistical considerations of such a trial would be substantial and challenging.

LATROBE VALLEY BETTER HEALTH PROJECT 45 46 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE APPENDIX 1 PRE AND POST INTERVENTION SURVEYS

LATROBE VALLEY BETIER HEALTH PROJECT 47 CENTRE FOR HEALTH, EDUCATION AND SOCIAL SCIENCES

LATROBE VALLEY BETTER HEALTH PROJECT Interviewer:

TELEPHONE QUESTIONNAIRE Phone No.: _

Location:

PostCode:

INTRODUCTION

My name is I'm ringing from Monash Gippsland.

We are doing a survey on nutrition and on accident prevention on behalf of the Latrobe Better Health Committee. Can I ask you a few questions.

Do you live in a town or the country? (Name of town! district! area) _

What is your postcode? _

Would you answer a few questions about safety in the home? It will not take very long.

1. Can you tell me some accident prevention features of your home? (Things that make people in your home less likely to have accidents or injuries such as smoke detectors or eye protection for working around the home)

2. Can you tell me some ways in which you could improve the safety of your horse to prevent accidents?

3. Do you know anywhere in your town/shire where you can purchase safety products for leisure, sport or home activities? Please specify:

4. Have you bought any safety items for a family member or for your home, or garage, or yard in the last 12 months? Please specify:

48 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 5. Can you suggest some ways in which sports injuries could be prevented?

6. Are you aware of any accident prevention or safety programs in your town or shire?

YES NO

If Yes please list:

7. In the past two weeks has anyone from your household suffered an injury (at home/work/school!in traffic/sport, etc)? YES NO

If Yes location (home/ school! etc)

activity (riding bicycle/ playing football! etc)

mechanism (burn! fall!.hit by car/ etc)

required medical treatment (hospital admissionlhospital emergency department! G.P. other/ none)

Repeat if more than one person from the household injured in past fortnight:

location (home/ school! etc)

activity (riding bicycle/ playing football/ etc)

mechanism (burn! fall! hit by car/ etc)

required medical treatment (hospital admission! hospital emergency department!G.P.Iother/ none)

Would you mind answering a few questions about food?

(8 questions on nutrition asked but not reproduced here. See Harvey & Higgins, 1997)

Demographic Data

1. How many adults (18 years and over) live in your home?

2. How many children (under 18years) normally live in your home?

3. How old are the children?

LATROBE VALLEY BETIER HEALTH PROJECT 49 4. How many persons aged 65 years and over live in your home?

5. Is your home you are currently in being rented? YES NO

6. What is your age group? under 20 years

20 - 45 years

46 - 65 years

over 65 years

7. Record of sex of correspondent Male

Female

Thank you for answering our questions

50 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE LVBHP 1995 Questionnaire

LATROBE VALLEY BETTER BEALm PROJECT 1995

TELEPHONE QUESTIONNAIRE

Interviewer: Phone No:

My name is _ 1 am ringing from Monash University.

We are doing a survey on nutrition and on accident prevention. Your phone number has been randomly selected, I do not know your name or address. Can I ask you a few questions? This will take about 10 minutes of your time.

Do you live in a town/the country? Name oftown/district/area _ Postcode? ------How long have you lived in the Latrobe Valley? _ Would you answer a few questions about safety in the home?

1. Can you tell me some accident prevention features of your home? (Things that make people in your home less likely to have accidents or injuries. For example, smoke detectors or eye protection for working around the home)

(a)No= _

(b) List

2. Can you tell me some ways in which you could improve the safety of your home to prevent accidents?

(a)No= _

(b) List

LATROBE VALLEY BETTER HEALTH PROJECT 51 3. Do you know anywhere in your town/shire where you can purchase safety products for leisure, sport or home activities?

(a) YES Q NOQ DON'TKNOWQ

(b) If YES, please specify

4. Have you bought any safety items for a family member or for your home, garage, or yard in the last 12 months?

(a) YES Q NOQ DON'TKNOWQ

(b) If YES, please specify

(d) Where did you get information about safety products?

5.. Can you suggest some ways in which sports injuries could be prevented? (a) No =------(b) List

6. Are you aware of any accident prevention or safety programs in your town or shire?

(a) YES Q NOQ DON'TKNOWQ

(b) If YES, please specify

52 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 7. In the past two weeks has anyone from your household participated in organised sport, such as training, a competition or through a club?

(a) YESa NOel DON'T KNOW a

(b) If YES who (age and sex)?

what sport?

how many times?

how long each time?

Repeat if more than one person from the household has participated in organised sport in the past fortnight.

8. In the past two weeks has anyone from your household suffered an injury (at home/work/schoollin traffic/sport, etc)?

(a) YES Cl NOel DON'T KNOW Cl

(b) If YES, what happened?

If YES, what location (home/schoolletc)?

what activity (riding bicycle/playing footballletc)?

how did it occur (burn/falllhit by car/etc)?

what was the medical treatment required (hospital admission/hospital emergency department/G.P Jother/none)?

Repeat if more than one person from the household injured in past fortnight:

What happened?

LATROBE VALLEY BEITER HEALTH PROJECT 53 If YES, what location (home/school/etc)?

what activity (riding bicycle/playing football/etc)?

how did it occur (burn/fall/hit by car/etc)?

what was the medical treatment required (hospital admission/hospital emergency department/G.P .Iother/none)?

Would you wind answering a few questions about food?

(7 questions on nutrition asked but not reproduced here. See Harvey & Higgins, 1997)

9. (a) Have you heard of the Latrobe Valley Better Health Project?

YESD NOD

(b) If YES, how did you hear of it?

TVD radio D newspaper public event D

other

What was the nature of the information?

YESD NOD DON'T KNOW D

(d) If YES, list and state how involved (eg organised activity themselves, attended education session).

Demographic Data

I . How many adults (18 years and over) live in your home?

2. How many children (under 18 years) normally live in your home?

3 . How old are the children?

4. How many persons aged 65 years and over live in your home?

5 . Is the home you are in currently being rented? YES a NOD

54 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 6. What is your age group?

under 20 years (J 20 - 45 years (J 46 - 65 years (J over 65 years (J

7. Record of sex of respondent

Male Female

Thank you for answering our questions

LATROBE VALLEY BEITER HEALTH PROJECT 55 56 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE APPENDIX 2 COMPARISON OF PRE AND POST INTERVENTION SURVEY SAMPLES

LATROBE VALLEY BETIER HEALTH PROJECT 57 Table 1: Child age distribution, random household telephone surveys, Latrobe Valley Better Health Project evaluation.

Age group Pre-intervention, 1992 Post-intervention, 1995 0-4 years 24.3% 17.3% 5-9 years 29.0% 24.8% 10-14 years 21.3% 36.5% 15-17 years 22.7% 20.3% Unknown 2.7% 1.1%

Table 2: Post code distribution, random household telephone surveys, Latrobe Valley Better Health Project evaluation.

Postcode Pre-intervention, 1992 Post-intervention, 1995 3825 25.5% 27.3% 3840 29.2% 26.5% 3842 8.0% 8.8% 3844 34.9% 33.0% 3854 0.5% 0.8% 3856 0% 1.0% 3860 0% 0.3% 3869 1.9% 1.8% 3953 0% 0.3% 3999 0% 0.5%

Table 3: Respondent age distribution, random household telephone surveys, Latrobe Valley Better Health Project evaluation.

Age group Pre-intervention, 1992 Post-intervention, 1995 <20 years 6.1% 8.8% 20-45 years 51.7% 49.0% 46-65 years 24.3% 28.0% >65 years 17.3% 13.0% Unknown 0.5% 1.25%

Table 4: Adults per household, random household telephone surveys, Latrobe Valley Better . Health Project evaluation Number of adults Pre- intervention, 1992 Post-intervention, 1995 o 0.3% 1.3% 1 19.5% 21.3% 2 58.4% 53.3% 3 14.4% 16.8% 4 3.5% 5.3% 5 1.9% 1.0% 6 0% 0.3% Unknown/missing 2.1% 1.0%

58 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Table 5: Children per household, random household telephone surveys, Latrobe Valley Better Health Project evaluation.

Number of children Pre- intervention, 1992 Post-intervention, 1995 o 58.4% 57.0% 1 12.3% 11.5% 2 19.7% 17.5% 3 5.3% 9.0% 4 1.7% 3.7% 5 0% 0.5% 10 0.3% 0% Unknown/missing 2.1% 1.0%

Table 6: Respondents over 65, random household telephone surveys, Latrobe Valley Better Health Project evaluation.

Respondents Pre- intervention, 1992 Post-intervention, 1995 o 78.9% 83.0% 1 10.7% 9.0% 2 8.0% 6.8% 3 0.3% 0.3% Unknown 2.1% 1.0%

Table 7: Rented homes, random household telephone surveys, Latrobe Valley Better Health Project evaluation.

Rented Pre- intervention, 1992 Post-intervention, 1995 Yes 19.7% 19.8% No 76.8% 78.5% Unknown 3.5% 1.8%

LATROBE VALLEY BETTER HEALTH PROJECT 59 60 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE APPENDIX 3 STATISTICAL LOCAL AREAS FOR LATROBE VALLEY PROGRAM REGION AND COMPARISON OF SMALL RURAL CENTRE AREAS

LATROBE VALLEY BETTER HEALTH PROJECT 61 Latrobe Valley Program Region

Local Government Area Statistical Local Area Population 1991 (Pre 1994) (usual residents)

City ofMoe Moe 16913 City of Morwell Morwell Part A 25149 Morwell Part B 1340

City ofTraralgon Traralgon 19789 Shire ofTraralgon Traralgon Part A 3279 Traralgon Part B 1309 67779

Small RuralPopulationColacBaimsdaleEchuca(C)Horsham(C)MilduraBellarinePortlandWangarattaSaleWarmamboolStatisticalCentres2364013786104061084512633183511835915797195002375294256939(C)93311839(S)(C)(S)(C)1991(C)(RC)ComparisonLocal(C)(C)Part(C)PartAAreaA(usual* Arearesidents) BellarineHorsham(C)Echuca(C)ColacMildura(C)Mildura(S)WarrnamboolWangarattaColacSalePortland(C)(S)(C)(RC)(C)(Pre(C)(C)1994) MilduraBellarine (S)(RC)PartPartB*B 194603 Bairnsdale (C) Local Government Area

*The Rural and Remote Area Classification is based on statistical local areas (SLA). However, the Victorian Inpatient Minimum Database does not include a code for SLA, instead coding for local government area (LGA), as a geographic identifier. In some cases, LGAs consist of two SLAs, and since it was only possible to extract the injury data using LGA, it was not possible to adhere exactly to the rural and remote area classification structure. Consequently, Mi1dura (S) Part Band Bellarine (RC) Part A have been included in, and South Barwon C Pt B has been excluded from, the small rural centre comparison area. Narracan Shire has also been excluded due to its geographic proximity to the Latrobe Valley Program Region and possibly contamination.

62 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE APPENDIX 4 EMERGENCY DEPARTMENT PRESENTATIONS: POISSON REGRESSION ANALYSIS

LATROBE VALLEY BETTER HEALTH PROJECT 63 Table 1: Poisson regression analysis, emergency department injury presentation rates, Latrobe Valley Better Health Project, 1991/92-1995/96, Vic

Group StandardSignificanceSignificantDecreasingError0.02440.0279Trend0.01030.0110- 0.06250.0710Slope(Slope)P-value for slope (all(0-4ages)yrs) Home Home

Home NotBorderlineSignificantDecreasingsignificant0.02570.04160.02440.01390.02520.02300.03770.01880.017-80.03430.02270.03480.01660.05120.49850.00130.26000.02560.00760.02280.69530.0829-0.0101--0.08780.01560.06080.05850.02400.10060.07660.05170.04910.0201 violence * violence(25-64(15-24(5-14(65+yrs)yrs)yrs)* (10-24(25+ years)years) InterpersonalPlaygroundAllSportOthertargeted Equipment *crudeInterpersonalPlaygroundHome age group rates were used

64 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE APPENDIX 5 EMERGENCY DEPARTMENT PRESENTATIONS: LOGISTIC REGRESSION ANALYSIS

LATROBE VALLEY BETIER HEALTH PROJECT 65 0-4 YEAR AGE GROUP: UNINTENTIONAL INJURY

Home Injuries: model = trend + target + program.target 95% C.1. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.04620.00000.192813954.03Odds1942.9240.9317.2261.1990.9250.0230.9791.0020.8630.0181.1135.6993.9711.70* 0.8940.0206.4171.0441.096 OtherPreviousProgramInjuryEffectTrend(referenceon TargetedOthergroup)InjuryInjury Targeted Injury

Model Fit 11.85 5 0.0369 *

Sports Injuries: model = trend + target + program 95%C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.54490.00000.192511987.02Odds297.8910.0240.0580.9300.9521.0971.4370.0170.02810.371.70* 0.0200.0401.0221.156 OtherProgramPreviousInjuryTrendEffect(reference group) Targeted Injury

Model Fit 15.09 6 0.0196 *

Playground Injuries: model = trend + target + program 95%C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.35890.00000.397412301.96Odds301.4310.2640.0240.9640.9001.3390.0180.1881.0980.840.721* 0.0211.0980.2221.029 OtherProgramPreviousInjuryEffectTrend(reference group) Targeted Injury

Model Fit 10.93 6 0.0904

Playground Equipment Injuries: model = trend + target + program 95% C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.32610.00000.584012307.33Odds302.7710.2620.0240.9540.9061.3460.1860.0181.0870.960.301* 0.0210.2211.0181.104 OtherProgramPreviousInjuryEffectTrend(reference group) Targeted Injury

Model Fit 12.85 6 0.0455 *

All Targeted Injuries: model = trend + target + program. target 95% C.1. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00000.03550.198013986.341012.11Odds142.551.2010.9250.9780.0237.6690.0180.8641.0066.0541.1124.4211.66* 0.8940.0206.8141.0431.099 OtherPreviousProgramInjuryTrendEffect(referenceon TargetedOthergroup)InjuryInjury Targeted Injury

Model Fit 11.54 5 0.0417 *

66 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 5-14 YEAR AGE GROUP: UNINTENTIONAL INJURY

HomeInjuries: model = trend + target + program 95%C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00030.00000.149618370.02Odds1582.56112.952.4500.9740.0220.9140.0252.1410.8591.0232.081 * 0.9380.0230.9432.290 OtherPreviousProgramInjuryTrendEffect(reference group) Targeted Injury

Mode/Fit 25.65 6 0.0003 *

Sports Injuries: model = trend + target + program.target 95%C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.13430.10260.00000.07460.066815409.89Odds0.9970.0260.8200.9041.0190.8150.0211.0051.0271.1042.6712.243.363.18* 0.9180.0240.9530.9111.049 OtherProgramPreviousInjuryEffectTrend(referenceon OtherTargetedgroup)InjuryInjury Targeted Injury

Mode/Fit 27.49 5 0.0000 *

Playground Injuries: model = trend + target + program 95% C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00000.04970.056516982.91Odds148.351.4020.0260.8150.0221.2080.9281.0031.00013.853.64* 0.9040.0240.9631.301 OtherProgramPreviousInjuryEffectTrend(reference group) Targeted Injury

Mode/ Fit 20.80 6 0.0020 *

Playground EquipmentInjuries: model= trend + target + program 95% C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00000.00320.204215184.23Odds313.5010.9360.0280.4330.7210.9240.3521.0170.02311.618.71* 0.0250.9690.8210.390 OtherPreviousProgramInjuryTrendEffect(reference group) Targeted Injury

Mode/ Fit 14.42 6 0.0253 *

All TargetedInjuries: model = trend + target + program 95%C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00000.76840.000112533.33Odds1 16.110.9430.0240.9750.9280.0204.6145.2221.08310.09* 10522.361 0.0224.9090.9511.011 ProgramOtherPreviousInjuryTrendEffect(reference group) Targeted Injury

Mode/Fit 35.76 6 0.0000 *

LATROBE VALLEY BETIER HEALTH PROJECT 67 15-24 YEAR AGE GROUP: UNINTENTIONAL INJURY

Home Injuries: model = trend + target + program 95% C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.85830.000017997.47Odds1172.74154.641.6400.8570.9100.9150.0340.0301.4431.0810.031* 0.9920.8860.0321.538 OtherPreviousProgramInjuryTrendEffect(reference group) Targeted Injury

Model Fit 29.43 6 0.0001 *

Sports Injuries: model = trend + target + program 95% C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.11800.00000.006517523.53Odds152.340.0341.3670.8470.9230.0290.9871.1961.0192.4417.41* 0.0310.9290.9541.279 ProgramOtherPreviousInjuryEffectTrend(reference group) Targeted Injury

Model Fit 29.12 6 0.0001 *

Playground Injuries: model = trend + target + program 95% Col. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.02090.00230.000015467.05Odds481.8610.3680.7740.9790.3020.0310.8940.9760.03715.339.31* 0.0330.9340.8710.334 OtherPreviousProgramInjuryTrendEffect(reference group) Targeted Injury

Model Fit 17.66 6 0.0071 *

Playground Equipment Injuries: model = trend + target + program 95% Col. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00380.00000.057214488.68Odds394.5510.0380.9380.9050.0200.0080.0310.7151.0023.6218.36* 0.8190.0340.9520.013 OtherProgramPreviousInjuryEffectTrend(reference group) Targeted Injury

Model Fit 11.72 6 0.0686

All Targeted Injuries: model = trend + target + program 95% C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00000.786611670.52Odds159.380.9420.0330.8820.9283.5173.1340.0291.08210.07* 10075.161 0.0310.9051.0103.320 OtherProgramPreviousInjuryTrendEffect(reference group) Targeted Injury

Model Fit 35.49 6 0.0000 *

68 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE 25-64 YEAR AGE GROUP: UNINTENTIONAL INJURY

Home Injuries: model = trend + target + program.target 95%C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00000.423311017.10Odds1120.49125.501.2562.9650.0110.8891.1063.4180.0100.8450.9481.02310.64* 14909.211 0.9850.0100.8673.1841.178 OtherProgramPreviousInjuryEffectTrend(referenceon OtherTargetedgroup)InjuryInjury Targeted Injury

Mode/ Fit 5.22 5 0.3902

Sports Injuries: model = trend + target + program 95% C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00930.00000.15301Odds224.1111.2600.6310.0120.5500.9440.0101.0331.0092.046.77* 11618.161 0.0110.9760.5891.141 OtherProgramPreviousInjuryEffectTrend(reference group) Targeted Injury

Mode/Fit 9.80 6 0.1333

Playground Injuries: model = trend + target + program.target 95% C.1. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00730.00000.506119195.97Odds1355.56116.650.0120.9171.3050.3191.0420.2440.7820.9471.0270.01017.210.44* 0.0110.9860.8471.1660.279 OtherProgramPreviousInjuryEffectTrend(referenceon TargetedOthergroup)InjuryInjury Targeted Injury

Mode/Fit 6.33 5 0.2754

Playground Equipment Injuries: model = trend + target + program 95% C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00280.33740.000017921.59Odds485.7611.3770.0110.9400.0070.0161.0690.0091.02118.920.92* 0.0100.9801.2130.011 OtherPreviousProgramInjuryEffectTrend(reference group) Targeted Injury

Mode/Fit 8.83 6 0.1832

All Targeted Injuries: model = trend + target + program.target 95%C.I. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00000.562811625.50Odds1120.31121.664.4421.2150.0110.9021.0830.0100.9530.8621.0273.86910.33* 15709.551 0.0114.1450.9890.8821.147 OtherProgramPreviousInjuryEffectTrend(referenceon TargetedOthergroup)InjuryInjury Targeted Injury

Mode/ Fit 6.90 5 0.2283

LATROBE VALLEY BElTER HEALTH PROJECT 69 65 YEARS AND OVER AGE GROUP: UNINTENTIONAL INJURY

Home Injuries: model = trend + target + program 95% Col.

Variate Odds Ratio Lower Upper- - c2 df p-value Baseline Odds 0.49330.90880.000013885.25175.381.4090.0160.8600.9361.7210.0211.1441.0320.470.011* 0.9920.9830.0191.557 OtherProgramPreviousInjuryTrendEffect(reference group) Targeted Injury

Model Fit 7.18 6 0.3045

Sports Injuries: model = trend + target + program.target 95% C.1. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.01340.67480.00000.400812046.12Odds184.590.9412.6080.0041.1180.0160.7250.0290.0231.0991.1370.180.716.121* 0.0190.9081.7070.0111.017 OtherProgramPreviousInjuryEffectTrend(referenceon TargetedOthergroup)InjuryInjury Targeted Injury

Model Fit 7.78 5 0.1687

Playground Injuries: model = trend + target + program 95% C.1. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.67790.00000.495812109.68Odds289.7210.9420.0400.0160.7420.0220.0781.1551.0960.170.461* 0.0190.9260.0561.016 OtherProgramPreviousInjuryEffectTrend(reference group) Targeted Injury

Modelp-value0.4201Fit6df Upperc2Lower Odds Ratio 6.03 Variate 95% C.I. Playground Equipment Injuries: reliable model could not be obtained All Targeted Injuries: model = trend + target + program

Baseline0.96780.00000.635013947.86Odds197.710.8711.4920.9420.0160.0211.8181.1551.0370.230.001* 0.0180.9881.0031.647 OtherProgramPreviousInjuryEffectTrend(reference group) Targeted Injury

Model Fit 6.20 6 0.4016

70 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE INTENTIONAL INJURIES

Intentional Injuries: model = trend + target + program.target 95% Col. Variate Odds Ratio Lower Upper c2 df p-value Baseline0.00000.09160.018118383.42Odds1375.98127.681.3100.9092.9123.7030.0051.0260.0040.8980.8111.00815.592.85* 0.9510.8590.0043.2841.159 AgePreviousProgram25+ yearsEffectTrend (referenceon 25+10-24yearsyearsgroup) Age 10-24 years

Model Fit 3.95 5 0.5560

LATROBE VALLEY BETTER HEALTH PROJECT 71 72 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE APPENDIX 6 INJURY FREQUENCIES AND RATES

LATROBE VALLEY BETTER HEALTH PROJECT 73 Table 1: Unintentional2535329615-245-14298232543578122613861206109825-64482443598543518632576567344936185202210208194Total65+yrsyrsyrsyrs759755782588664home injury emergency department presentations, adjusted frequencies, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vie .. 1992/931993/941994/951995/961991/92 0-4 yrs

Table 2: Unintentional5-1415-2425-644828.162914.764450.944455.573810.753861.254348.934364.983289.862912.162814.944754.312446.552854.012835.543951.132758.033236.713311.042471.613715.924609.764788.214440.995109.55Total65+yrs12060.4610315.3611851.9711544.34yrs8999.08yrsyrs home injury emergency department presentations, crude age specific rates per 100,000, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vie. 1991/921995/961993/941994/951992/93 0-4 yrs

Table 3: Unintentional10052252892509162599199578542675-1415-2425-64439418401345426239268260259Total23965+yrs1yrsyrsyrs 10sports2756 injury emergency department presentations, adjusted frequencies, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vie. 1993/941994/951992/931995/961991/92 0-4 yrs

Table 4: Unintentional2074.822044.661213.081801.591331.621271.631228.232158.622349.591115.445-1415-2425-643495.532923.233776.343445.613503.77120.24695.12710.8027.01697.69694.3941.81624.7127.4414.22Total65+yrsyrsyrs108.75154.23yrs76.4530.6193.69sports injury emergency department presentations, crude age specific rates per 100,000, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vie. 1991/921994/951992/931995/961993/94 0-4 yrs

74 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE . Table 5:207.29204.48194.68166.95615642577566496Unintentional1261531471291562315.152829.652756.202892674.353343502650.415-1433732615-24749.95771.15103115104814.46168.4926.7225-64647.84824.7320853.07929.7463850.58688.94246.66279.0792747.97120118209.118071131001.07861221098.07131125.42120.2415.6816.1018.78424.6241.91625.7834.41316.3693322.0650.84703.27949807.7071.08972.0494.5296.057838.045.30Total359765+yrs0yrs0yrs419.45434.99443.83508.95608.99535.66519.88524.37546.53535.17yrs 29393335272834 playground injury emergency department presentations, adjusted ageHospital.frequencies,ratesspecificper 100,000,Latroberates LatrobeperValley100,000,ValleyBetterLatrobeBetterHealthHealthProjectValleyProjectRegion,BetterRegion,HealthLatrobeLatrobeProjectRegionalRegionalRegion,Hospital,Hospital,LatrobeVie. RegionalVie. 1995/961994/951993/941992/931991/921995/961992/931993/941995/961994/95 Table 7: Unintentional playground equipment injury emergency0-40-4yrsdepartmentyrs presentations, adjusted Table 8:6: Unintentional playgroundplayground injuryequipmentemergencyinjury departmentemergency presentations,department presentations,crude age specificcrude

LATROBE VALLEY BETTER HEALTH PROJECT 75 Table 9: All targeted4747455415-2448273885145912495178112912555-1411571183103025-64101210911585176311241589771995217200219215204Total65+yrsyrsyrsyrsunintentional794698625827800 injury emergency department presentations, adjusted 1994/95 frequencies, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vie. 1993/941992/931995/961991/92 0-4 yrs

Table 10: All15-245-146532.7925-644263.944253.893869.624726.67targeted8559.148695.658952.163280.362725.452957.066344.312996.102843.335074.326034.032977.506880.3310097.836392.538251.229421.639617.899233.669264.15Total65+yrs12492.1912140.6710843.5612754.47yrs9565.35yrsyrsunintentional injury emergency department presentations, crude age specific rates per 100,000, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vie. 1991/921992/931995/961994/951993/94 0-4 yrs

Table 11: Other1180127415-241261136913285-1425521521725225-64326406470440318465266269420340376133109142129135Total65+yrsunintentionalyrsyrsyrs142123175161128 injury emergency department presentations, adjusted frequencies, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vie. 1995/961992/931993/941994/951991/92 0-4 yrs

Table MONASH12: Other15-245-142285.622735.4825-642610.302849.962279.273331.421647.031813.001890.822037.351774.761881.271764.601577.061495.611741.831688.041009.132042.781897.131097.811179.661247.791246.55UNIVERSITY1747.97Total65+yrsunintentionalyrs2483.042206.002678.301957.191920.67yrsyrs ACCIDENTinjuryRESEARCHemergencyCENTREdepartment presentations, crude age specific rates per 100,000, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vie. 1991/921995/961992/931993/941994/95 0-4 yrs 76 Table 13:PlaygroundAge6120.964820.916593.746076.615761.39AllPlayground177.21175.43142.44145.201779.211670.611740.671560.091276.921062.431613.051178.641228.031187.62Sport683.38783.61702.49585.21747.02standardised166.6targeted4190.354195.294580.673799.963172.88Other unintentional rates per 100,000, Latrobe Valley Better Health Project equipment 1992/931993/941994/951995/96 1991/92 Region, Latrobe Regional Hospital, Vic. Home

Table 14: Emergency department presentations for intentional injury inflicted by others, adjusted frequencies, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vic.

19120721218118710-2425 yearsyears208259250243163 and over 1995/961992/931994/951993/941991/92

Table 15: Emergency department presentations for intentional injury inflicted by others, crude age specific rates per 100,000, Latrobe Valley Better Health Project Region, Latrobe Regional Hospital, Vic.

417.55408.6310-24414.54464.60476.67251456.861342.991434.641191.84920.12yearsyears and over 1992/931994/951995/961993/941991/92

LA TROBE VALLEY BETTER HEALTH PROJECT 77 78 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE APPENDIX 7 STRATEGIC LINKS WITH LOCAL ORGANISATIONS

LATROBE VALLEY BETIER HEALTH PROJECT 79 CASE STUDY ONE

Partnership With Police To Reduce Violence, Especially Alcohol-Related Violence - Interview With Licensing Inspector, Victoria Police

What involvement did you have with La Trobe Shire Safe Communities Program?

The initial involvement with the La Trobe Shire Safe Communities Program (and its program co-ordinator) was through the Police Community Consultative Committees (PCCCs) which were established in the major communities of La Trobe Shire in late 1992 and early 1993 with an initial focus on reducing public violence. There was a culture of violence on the streets in the Valley, especially in and around licensed premises, police were regularly being assaulted in brawls. The area had the second highest incidence of assaults in Victoria.

The Safe Communities' co-ordinator was active in the Traralgon PCCC (working on the issue of youth and alcohol) and later became a member of the Gippsland Police Region CC executive.

What did the collaboration achieve?

During 1993 the police had tried reactive policing to combat the problem of street violence, with little success. In 1994 a Local Industry Accord was struck between hotel licensees and police where they agreed to work together (through the adoption of best practices) to promote responsible service of alcohol in licensed premises. The support of community organisations was vital to the success of the Accord. The Safe Communities' co-ordinator spoke at the inaugural meeting on general community safety issues and has contributed heavily in the areas of responsible serving of alcohol (through the promotion of formal training for hotel staff), Latrobe Drinksafe and, more recently, the Gippsland Anti-violence project which has grown out of the PCCC's work. The Accord appears to be working. There was a 50% reduction in arrests for assaults in and around licensed premises in the Traralgon CBD (Christmas period 1994/95 compared to Christmas period 1995/96) and wilful damage charges also halved.

The La Trobe Shire Safe Communities Program has been particularly active in Latrobe Drinksafe which commenced at the end of 1994. The Safe Communities' co-ordinator involved the Traralgon Community Health Centre people and called a meeting of police, licensees and other groups working on the youth alcohol problem. He was involved with getting sponsors, teeing up licensed premises, publicity, in fact, the whole marketing of the Drinksafe concept. He worked "hands on" in the pubs. It was skilled work as it was important that the leaders were not seen as wowsers. The Safe Communities' co-ordinator could talk to participants about the positives and negatives of drinking, on their own level. There is anecdotal evidence that the program was successful, for example, one of the participants, a local tow truck driver, realised that he was driving on the job with a blood alcohol content well over .05 when drinking at his normal rate.

The Safe Communities' co-ordinator also brought sporting clubs onside. There was a very ordinary pattern of behaviour regarding alcohol use in some football clubs; club members were not good role models. His link with the sporting sector (through the La Trobe Shire Safe Communities Program's sponsorship of the Gippsland Latrobe Football League) has resulted in two local football clubs (Morwell and Traralgon) volunteering to participate in the Alcohol and Sports Clubs Project which was recently established in Victoria.

The La Trobe Shire Safe Communities Program has also been involved in the Domestic Violence initiative. The Safe Communities' co-ordinator took a lead role in organising the Face-to-Face day which brought together over 100 individuals from agencies working on domestic violence to discover how they can better work together. There was great networking and an honest sharing of information. This kind of initiative is a factor that has led to the Department of Justice funding the Gippsland Anti-Violence Project, a three year action research project to document best practice to reduce domestic violence through projects involving the collaboration of police, local agencies and the community.

80 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Would the initiatives have happened without the involvement of La Trobe Shire Safe Communities Program?

The PCCCs are all about collaborative action. Alcohol and community violence issues require that communities work together. You, therefore, must have people involved who bring in fresh ideas and facilitate linkages. The Safe Communities' co-ordinator fed information to the PCCCs about strategies that have been put into place in Australia and overseas. He brought the health sector and the sports sector into the work of the PCCCs.

We have come a long way together. The police have driven the PCCCs but they are down to the bone with staffing. There is only one Crime Prevention Officer for the district which covers the area from the Bunyip River to the border. The police are not able to do things in the local community that the La Trobe Shire Safe Communities Program is able to do. The recently established La Trobe Safe Communities Forum will involve a broader base of community agencies and individuals and, hopefully, will lead to greater collaboration on the whole range of community safety issues.

CASE STUDY TWO

Partnership with Gippsland Latrobe Football League to promote safety in sport - interview with elected officer bearers of the Gippsland Latrobe Football League

What involvement did you (and your organisation) have with La Trobe Shire Safe Communities Program?

Our main involvement is that the La Trobe Shire Safe Communities Program is the health sponsor of the Gippsland Latrobe Football League with funding from the Victorian Health Promotion Foundation. The League receives $15,000 sponsorship in 1995 and 1996 to promote the "Play Safe Sport" message to players, trainers, coaches and football followers.

What did the collaboration achieve?

We developed the "Play Safe Sport" message which is prominently displayed on players' jumpers, ground signage, banners (displayed during games and promotions in local schools) and in all our League print materials, especially our weekly League publication "The Follower". Working with the co-ordinator of the La Trobe Shire Safe Communities Program we promoted the message through articles on football safety in "The Follower" and advertisements in the local media. As a result of the sponsorship we introduced or expanded our activities in terms of training in injury prevention for coaches, club trainers and administrators (providing accreditation through courses and workshops) and improving grounds (we shifted games from unsafe grounds during the season). We promoted safety measures (for example, the wearing of mouthguards and helmets) and a Code of Conduct (including a Code of Conduct award in the Thirds competition) to players and clubs.

The second year of the "Play Safe Sport" campaign has allowed us to make some comparisons with 1995. CA SICO, the League's medical insurance company informs us that, to November 1996, the member clubs had submitted 44 claims for injuries which cost $3,955 compared to 79 claims in 1995 which cost $13,059. Even allowing for some late claims this season, this represents a dramatic drop both in the number of injuries and their seriousness (confirmed by a case by case examination). The League also operates "Loss of Income" Insurance. The audited reports shows that claims totalling $28,758 were paid this year compared to $42,980 in 1995.

Also of interest are the Tribunal statistics. The Tribunal sat on 12 occasions this year compared to 30 occasions in 1995. A total of24 reports were laid by umpires in 1996 compared to 57 in 1995. There were

LATROBE VALLEY BETTER HEALTH PROJECT 81 37 player weeks lost through suspension in 1996 compared to 74 in 1995. These figures point to another aspect of the safety issue in sport and suggest a dramatic improvement in 1996.

Prior to the La Trobe Shire Safe Communities Program's sponsorship, the League was sponsored by the Gippsland Community Road Safety Council (whose message was "Drink, Drive, Bloody Idiot"). Under our new arrangements with the La Trobe Shire Safe Communities Program we expanded our activities to reduce the problems associated with alcohol in our clubs. The Safe Communities' co-ordinator has encouraged our clubs to be involved in the Alcohol and Sports Clubs Project, an Australian Drug Foundation initiative (two of our clubs are involved in the pilot to be launched next week), to introduce light beer at functions and worked with us to develop a policy for a dry area at the Grand Final ground. He promoted the dry area on local radio and the initiative received very positive press. There have been no alcohol related problems at games. Together we have created a more responsible culture.

Would the initiatives have happened without the involvement of the La Trobe Shire Safe Communities Program?

Permanent changes have happened. As a league, we were always concerned about player safety (we have an active trainers' association) but the involvement of the La Trobe Shire Safe Communities Program has given us a real focus and direction. The Safe Communities' co-ordinator supplied us with facts and figures on football injuries, information on health-related issues e.g. he provided us with information to support the League's policy on infectious diseases, kept the League abreast of funding opportunities (for example, the VicHealth Sports Safety Equipment Awards) and gave us access to the latest information on sports injury prevention through the VicHealth Sports sponsorship seminars.

The opportunity to promote the sports safety message has enabled the League to present a very professional face to the community. It helped us develop a good public image, presenting football as family entertainment and a game that cares for the safety of its players, especially the young players. All of our clubs have annual incomes of at least $200,000 but most club workers are volunteers. The "Play Safe Sport " sponsorship gives us a professional and caring image, rather than a rough "country hick" one, and helps us to recruit players, volunteer club workers and families of football followers.

I like the way the Safe Communities' program co-ordinator works. He does not impose ideas. Rather he says "Have you heard about this?" or "I wonder how the end-of-year function would go if it was "smoke free"?". All League functions in 1995/6 were "smoke free", including League meetings. We state on invitations that the functions are "smoke free", put signs up at the doors and smokers go outside to smoke• there is no negative feedback.

CASE STUDY THREE

Partnership with Council and local organisations to promote safety across a range of issues -interview with former local Councillor and ~ayor

What involvement did you (and your organisation) have with the La Trobe Shire Safe Communities Program?

I was involved in the La Trobe Shire Safe Communities Program in a number of ways through the many positions I've held in the community. I was a local Councillor (and mayor) in Traralgon and involved in the development of Municipal Public Health Plans for the Council. I was on the Gippsland Police Community Consultative Committee. I am also the Chairman of the Allambie Elderly Citizens' Village. I had a lot of contacts with the La Trobe Shire Safe Communities Program over four years and became a member of the La Trobe Shire Safe Communities Program Management Committee twelve months ago.

82 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE What have the collaborations between local organisations and the La Trobe Shire Safe Communities Program achieved?

At the Allambie Elderly Citizens' Village we have introduced a falls prevention project which "picked up" the work done in the Safe Communities' Elderly Falls program. All falls are monitored through a data collection system and we have introduced exercise sessions and a program of medication management.

I think a particular contribution of the La Trobe Shire Safe Communities Program was the Drinksafe campaign which was undertaken by the Traralgon PCCC. The Safe Communities' co-ordinator initiated the marketing of the non-alcoholic cocktail to young people and was strongly involved in getting the Council to ban the consumption of alcohol in public areas in the CBD. The $100 on-the-spot fines were collected and deposited in the Traralgon City Youth Development fund. The Safe Communities' co-ordinator was a driving force on the committee which successfully sold this idea to Council. He's a mover and a shaker and this work was the forerunner to the later, successful Local Industry Accord between Police, hotel licensees and the La Trobe Council on responsible service of alcohol.

The La Trobe Shire Safe Communities Program also provided guidance to the Council on developing safer playgrounds in the Shire. The Safe Communities' co-ordinator brought the issue to the Council's attention, particularly their public duty responsibilities and the likelihood of Council being sued if accidents occurred because playgrounds were unsafe. The audits of playgrounds were done because the Safe Communities' co• ordinator "pushed the barrow" for them to Councils.

The Safe Communities' co-ordinator has put ideas forward in a lot of areas. He is a good communicator and participates well in groups. In the area of family violence he has been part of the group that has instigated the Gippsland Anti-Violence Project, funded by the Department of Justice, an action research project which will focus on reducing violence (particularly family violence) in the region. In the nutrition area a lot has come from the enthusiasm of the Safe Communities' co-ordinator -he "fired the bullets".

Would the initiatives have happened without the involvement of the La Trobe Shire Safe Communities Program?

Community education is a big part of the role played by the Safe Communities Program. The awareness of safety issues in the community is much broader now because of the work of the Safe Communities Program. Safety issues are now entrenched in the Municipal Public Health Plan, which re-enforces Council's role in supporting the World Health Organisation's "Safe Communities" concept and in specific areas such as home safety, footpath safety and safe playgrounds.

CASE STUDY FOUR

Partnership with local government to make playgrounds safer -interview with Parks and Gardens Superintendent, Local Government Municipality

What involvement did you have with the La Trobe Shire Safe Communities Program?

I was the nominated person from the municipality on the playground safety committee. I think it was an initiative of the Safe Communities' co-ordinator. I had no idea of what I was going to when I set off to the first meeting. It was attended by three Parks and Gardens supervisors (from Moe, Morwell and Traralgon), the La Trobe Shire Safe Communities Program, VicRoads and MUARC. The committee met on an irregular basis over about every three months. The Safe Communities' co-ordinator talked about playground safety and gave us data on injuries and we shared information on what we had been doing lately in terms of playground safety. We had already had our playgrounds audited by an outside consultant from Melbourne and I had his full report and recommendations. When the consultant's report came in we had a

LATROBE VALLEY BETIER HEALTH PROJECT 83 maintenance man do the urgent work as soon as possible, the not-so-urgent work was put into our forward program.

What did the collaboration achieve?

I think the meetings were a waste of time as far as Parks and Gardens Superintendents were concerned, they were a low priority for superintendents and attendance dropped off. The Safe Communities' co-ordinator gave us a lot of statistical information (data on playground injuries) which was of no practical use. In terms of how I did my job, I felt like the meat in the sandwich. I had the playground auditor's recommendations and reports from my ground staff but I was forever being told by Councillors and locals to prove there'd been accidents on the particularly dangerous pieces of equipment that we wanted to remove. To a certain extent the Councillors were unwilling to act because the ratepayers did not support the changes. For example, there was some old plough equipment donated by an influential local family but no one was willing to make the decision to remove it. We also had a flying fox which was dangerous but very popular. Councillors faced political flack in their wards; they were being told "I always take my grandchildren to this playground, if you remove this equipment you'll lose my vote". The Council wards were very small then (before amalgamation) so Councillors took these threats seriously.

Did you enlist the support of the La Trobe Shire Safe Communities Program when you faced this opposition?

No I didn't think of involving the Safe Communities' co-ordinator.

Would the Council's action on playgrounds have happened without the involvement of the La Trobe Shire Safe Communities Program?

It was happening but not happening fast because of the politics. The playground part of the La Trobe Shire Safe Communities Program was grinding to a halt prior to amalgamation. I don't think we had a meeting in the twelve months before amalgamation and I've had no contact since.

The change of thinking came with the amalgamation and appointment of commissioners, "the new broom sweeps clean". The commissioners were not answerable to ratepayers and were quick to respond to some expensive litigation cases arising from playground injuries. Within a week or two of the amalgamation some of the contentious removals were done. The Council now has two people on permanent playground maintenance and everything they do is recorded. At the end of every month the Parks and Gardens Co• ordinator has to do a status report to the asset manager of Council.

I think that progress will still be made after the elected Councillors are returned in March 1997. The wards are bigger and the Councillors have much broader responsibilities; they will be much more able to see "the bigger picture" than before. The Parks and Gardens Department of the La Trobe Shire has recently been successful in winning the CCT contract for the provision of maintenance services within the four main urban areas of the shire. The Department sees total compliance with the specific Australian Standards with regard to playground equipment construction, installation and maintenance as essential.

84 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE APPENDIX 8 MATCHING OF PROGRAM OBJECTIVES WITH ACHIEVEMENTS MEASURED

LATROBE VALLEY BETTER HEALTH PROJECT 85 86 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE Objective Evidence for achievement

• to increase community awareness of injury prevention and create a "Safe • significant increase in proportions of households able to list safety features oftheir Community" environment homes

• significant increases in proportions of households knowing where to purchase safety products

• significant increase in proportions of householders able to indicate what prompted their safety purchases in previous 12 months

• anecdotal evidence from key informant interviews • (no significant difference in proportions of householders able to list ways in which safety of home could be improved) • (no significant difference in proportion of householders able to list ways to prevent sports injury) • (no significant difference in number of safety features per house)

• to develop and implement strategies which will provide an overall reduction in the • statistically significant reductions in unintentional home injury for all ages except number and severity of injuries within the Latrobe region 65 yrs+, unintentional playground injury for 5-14, 15-24 and 25-64 yr olds, and unintentional sport injury among 15-24 yr olds • statistically significant reductions in intentional injury inflicted by others for 10-24 yr olds

• to reduce the number of hospital bed days incurred as a result of injuries not evaluated as a result of changes to the data system for hospital admissions

• to reduce the incidence of death due to injury not evaluated since the numbers were too small to identify any effects of the intervention

• to reduce hazards • replacement of unsafe playground equipment

• (no significant difference in proportion of households purchasing safety items in previous 12 months)

• to increase the use of safety devices and equipment • upgrading undersurfacing in municipal and private playgrounds

• (no significant difference in proportion of households purchasing safety items in previous 12 months) Objective Evidence for achievement

• to collaborate with the Latrobe Regional Hospital to provide a display of safety • Safety Features Display Home constructed and open to public for 8 weeks promotion in a home setting

• to provide a central location for information on child safety products • permanent safety display at Traralgon campus of Latrobe Regional Hospital

• to coordinate the dissemination of information about safety in the home and injury • home safety education sessions prevention strategies and equipment • home safety training for professional groups

• mobile safety product display

• to provide a venue for child safety education • Safety Features Display Home open to public for 8 weeks

• to provide a venue for health promotion and education needs of parents with young • Safety Features Display Home open to public for 8 weeks children

• to collaborate with local government to ensure all municipal playgrounds are • former local government areas represented on Working Party assessed against safety standards • some municipal playground audits conducted

• to encourage all municipalities to produce a playground strategy which includes • two of three former local governments developed strategy mechanisms for regular safety audits

• to inform the community of the nature of injuries associated with playgrounds and • media publicity to provide them with strategies to avoid such injuries

• to provide injury prevention information to community groups with existing • not evaluated playgrounds and to those designing future play facilities

• to raise community awareness of playground safety issues generally • not evaluated

• to implement a comprehensive sports injury control program, risks associated with • program implemented in football including injury prevention in coach and training the athletic activity and the necessity for conditioning programs courses, Play Safe Sport sponsorship, media publicity

• to bring together relevant representatives to provide advice and assistance in • wide representation on Working Party reducing the injuries targeted

• to run an educational and consultative process throughout the Latrobe Valley • series of sports injury prevention displays concerning sports injuries • media publicity

• to assess the nature and frequency of sports injuries • VISS data utilised Objective Evidence for achievement

• to promote awareness and understanding of youth alcohol issues

• to establish community-based Youth Alcohol Working Parties in the cities ofMoe, • accomplished in collaboration with the Police Community Consultative Committees Morwell, and Shire of Traralgon, with membership consisting of a range of groups such as young people, youth workers and community representatives drawn from the local Council, parents, schools, and other community groups

• to provide information regarding attitudinal, behavioural, social and environmental variables affecting the use of alcohol • to assist locally-based Youth Alcohol Working Parties to identify factors which foster al alcohol misuse by young people in their own town

• to assist locally-based Youth Alcohol Working Parties to address these factors via • strategies implemented include promotion of non-alcoholic cocktails, youth drop in the development and implementation of action plans centres, responsible serving of alcohol courses, Liquor Industry Accord, Drink Safe, legislative changes 90 MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE REFERENCES

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