INJURY PREVENTION AND SAFETY PROMOTION BASED ON SAFE COMMUNITY PRINCIPLES IN THE BALTIC SEA REGION STATES. Anna Halonen

INJURY PREVENTION AND SAFETY PROMOTION BASED ON SAFE COMMUNITY PRINCIPLES IN THE BALTIC SEA REGION STATES Anna Halonen

About the author Anna Halonen has been working as project coordinator for Finnish Eurobaltic activities at Aleksanteri Institute, Finnish Centre for Russian and East European Studies at the University of Helsinki since 2004. She received her MA in International Conflict Analysis from the University of Kent in 2002. A publication of: Aleksanteri Institute Töölönkatu 3 A (PO Box 42) FIN-00014 University of Helsinki www.helsinki.fi/aleksanteri ISBN 952-10-2600-6 Printed by Multiprint Oy Design and layout by Metaneira Oy Helsinki, 2005

Contents Eurobaltic Foreword 1. Conceptual and Operational Framework of the Report: Aims, Methods, Material and Definition of the Central Concepts 1.1. Aims, Methods and Material of the Report 1.2. Definition of Injury and Injury Prevention 1.3. Definition of Safety and Safety Promotion 1.4. Links Between Safety and Health 1.5. Links Between Safety Promotion and Civil Protection 1.6. "Addressing All Kinds of Risks", Reasons to Promote Co-operation Between Different Sectors 2. The Safe Community Concept 2.1. Origins of the Safe Community Programme and Its Development 2.2. The Current Situation of the Safe Community Network 3. The Safe Community Programme in the Baltic Sea Region 3.1. Regional Activities and Co-operation 3.2. Other Injury Prevention and Safety Promotion Activities Involving the BSR Countries 3.3. The Current Situation in Injury Prevention and Safety Promotion in the BSR countries Denmark Estonia Finland Latvia Lithuania Norway Poland The Russian Federation Sweden 4. Conclusions - Future Challenges and Possibilities in Developing the Safe Community Programme Approach in the BSR References

EUROBALTIC This report is a part of a series of reports on the Eurobaltic Civil Protection Project. The Eurobaltic project is part of the wider Eurobaltic Programme for Civil Protection in the Baltic Sea Region (BSR). While the project is part-financed by the European Union BSR Interreg IIIB programme, it is also part of the activities of the civil security working body in the Council of the Baltic Sea States (CBSS). The Swedish Rescue Services Agency (SRSA) leads the project, and the whole network includes over twenty partners from all the BSR countries, including civil protection authorities, regions and municipalities, scientific institutions and non-governmental organizations. Within the project, Nordregio (Nordic Centre for Spatial Development, Stockholm) and the Aleksanteri Institute (Finnish Centre for Russian and East European Studies at the University of Helsinki) are responsible for research and reports. The reports will cover the whole spectrum of contemporary challenges to civil protection, from the point of view of the EU and the BSR in particular.

FOREWORD The aim of the Eurobaltic project is to improve abilities in protecting human life and the environment, as well as cultural heritage. The project will aim to support sustainable development in Safe Communities in the Baltic Sea Region. It also aims to promote safe industrial development and cooperation on spatial planning and sustainable land use management, thereby also contributing to the mitigation of risks of cross border effects of accidents. This report focuses on the development of Safe Communities in the BSR, and investigates the kinds of injury prevention and safety promotion policies and practices, based on the Safe Community principles, the countries in this region have. It became clear during research that the situation regarding the Safe Community programmes varies greatly between the different BSR countries - some countries have developed to a great extent practices based on these principles, whereas in other countries these practices are practically non-existent. It was therefore thought that the report would give a better account of the current situation if it described injury prevention and safety promotion practices more widely, rather than just limiting itself to the Safe Community activities. This has been done especially with those countries that have very few Safe Community activities. However, special attention has been given to the development of practices based on Safe Community principles in each country. One of the basic ideas of the Eurobaltic project is to promote the idea of a more holistic perspective into safety and security issues, in which governments, private actors, NGOs and other actors are all involved in the development, implementation and evaluation of policies and practices in this field. The Safe Community initiative, as a community-based safety promotion programme, gives an excellent example of a practice where different authorities and non-state actors are working in co-operation to promote safety and security in communities. The Safe Community initiative is also a very good example of developing multinational and cross-sectoral co-operation in order to promote safety in the society and the protection of health and environment. Therefore, it can be hoped that people from different sectors would find this report an inspiration in developing this kind of approach also in their own work. I would like to thank all the institutions and individuals who have participated in the project and in the preparation of this report.

7 1. Conceptual and Operational Framework of the Report: Aims, Methods, Material and Definition of the Central Concepts 1.1. Aims, Methods and Material of the Report This report will give an introduction to the injury prevention and safety promotion practices in the Baltic Sea Region, focusing in particular on the projects and programmes that are based on Safe Community principles. The first part of the report presents the conceptual and operational framework, including injury prevention and safety promotion, and their links to other fields, such as civil protection. The second part focuses on the Safe Community initiative, including its origins, its development over the years and the current situation. The conceptual framework regarding the Safe Community programme presented in this paper is strongly based on the framework created by WHO, the Quebec WHO Collaborating Centre for Safety Promotion and Injury Prevention, and the WHO Collaborating Centre on Community Safety Promotion at Karolinska Institutet, Department of Public Health Sciences, Division of Social Medicine, who have done pioneering work in this field. The third part of the report describes the present situation of the Safe Community programme in each BSR country. It also presents and analyses the injury statistics in the BSR countries, describes national actors, policies and practices towards injury prevention and safety promotion. It also presents injury prevention and safety promotion activities taken up by some municipalities in the BSR countries. The report aims, through this presentation and analysis, to offer examples and possibilities to authorities and other actors in different countries on how to develop policies and practices in these fields. A better understanding of the situation in different countries in this field can also create a better possibility of developing common practices and policies within the BSR countries and foster good regional co-operation. In addition, the report aims to study the role that the rescue services and other civil protection actors have and could have in injury prevention and safety promotion in the BSR countries. The idea behind this is the possibility of linking safety and preparedness considerations of civil protection to the efforts of preventing smaller scale accidents and safety promotion, which are often managed by public health authorities. An example of this kind of development has already taken place in Sweden, where in the beginning of 2002, responsibility for the Swedish Safety Promotion Programme was taken over by the Swedish Rescue Services Agency (SRSA) from the Swedish National Institute of Public Health. There are several reasons to study this kind of system more closely. First, safety promotion and civil protection have many issues in common. In many cases their work spheres overlap, although their backgrounds are rather different. Learning experiences from both fields can be beneficial when developing best practices, even if these fields will not be integrated. Secondly, there is increased awareness among the civil protection and rescue services authorities in many BSR countries that reacting to incidents and accidents is no longer enough, but a more holistic approach is needed, in which accident prevention measures have a stronger role, and in which co-operation between other actors in this field is more strongly emphasised. At the same time, awareness of safety promotion and injury prevention has increased all over the world, including the BSR countries. The material used for the report covers the existing documents and literature in the field. This includes a wide range of material from conferences, seminars and workshops in the field of injury prevention and safety promotion. In particular, this report has utilised the material from two seminars that were organized as a part of the Eurobaltic project: Workshop on establishing policies on Safe Community programmes, which was organized on 2-4 November 2003 in Stockholm, and Safe Community - Safe Industry that was held on 19-20 February 2004 in Skövde. In addition, information on the situation of different countries has been collected through the national focal points of the Eurobaltic project, as well as by sending questionnaires to authorities and experts in the BSR countries, and by visiting many governmental and other

8 websites. It must be noted that although all efforts have been made to get the same information from all countries, the material is not thoroughly comparable. 1.2. Definition of Injury and Injury Prevention From a common sense perspective, injuries are all about people being hurt. From a public health science perspective, WHO has defined injury in the following way: "Injuries are caused by acute exposure to physical agents such as mechanical energy, heat, electricity, chemicals, and ionising radiation interacting with the body in amounts or at rates that exceed the threshold of human tolerance. In some cases, for example drowning and frostbite, injuries result from the sudden lack of essential agents such as oxygen or heat. 1 This definition takes into account only the physical damage to a person, but recently many injury definitions have started to include psychological damage as well. From a common sense perspective, it has often been viewed that injuries are caused by accidents. Accidents are unintentional by their character and therefore it would be logical to conclude that so are injuries, too. However, public health science views the issue in a different way, and divides injuries into two categories: intentional and unintentional injuries. The first category is composed of violence directed towards others or oneself. Traditionally, there has been a sharp distinction between these two groups of injuries and practitioners, and researches of these two fields have not co-operated or collaborated. Such distinctions can be useful in advancing prevention efforts (i.e., a better understanding of the causes of different types of injuries is essential to their prevention, and e.g. the cause of suicide is probably rather different from the cause of an unintentional fall). However, distinctions are not always beneficial, as it can mean that these fields fail to take advantage of each other s knowledge in solving common problems. Furthermore, the distinction between different types of accidents is not always clear, e.g. a traffic accident may occur due to a suicide attempt. 2 Currently, many injury prevention programmes, Safe Community included, address both types of injuries. Unintentional and intentional injuries are often categorized in same ways. These categorizations include injury mechanisms - such as burn, drowning, poisoning and falling - and the body region of injury, e.g. neck or hip injury. Injuries and accidents are also categorized according to the environment they take place in, e.g. traffic, work, home and leisure time accidents and injuries, and according to the severity of the injury: fatal, need for hospital treatment, health centre, or home treatment. The impact of injuries to health and on society is great in terms of mortality, morbidity, disability and cost. Every year, more than five million people in the world die as a result of some kind of injury. This accounts for nine percent of all deaths, placing injuries in the top three causes of death. In the European region, injuries caused an estimated 800 000 deaths in 2002. 3 Moreover, for every death due to injuries there are hundreds, if not thousands, of individuals who are either hospitalised or treated in hospital emergency rooms or other health care facilities due to their injury. Furthermore, many people - especially in the developing countries - do not receive requisite treatment for their injuries. Many of the injured people suffer long-term or permanent disabilities. In addition to all human suffering, injuries cause a major loss of human resources and productivity for the societies and pose a great social and economic burden to them. The treatment and rehabilitation of injured persons often accounts for a large proportion of national health budgets. The burden of injury is unequally distributed. It is particularly heavy on low-income families and communities as they are more prone to injury and less likely to survive or recover from disability. 4 Despite the magnitude, the injury problem was neglected for a long time because of the traditional view of considering injuries as random unavoidable events. However, better understanding has changed the attitudes, and injuries are now known to be largely preventable. There is also a growing evidence base of effective prevention strategies for injuries, whatever their cause. Injury prevention includes a wide range of methods to address the issue, including data gathering and research; creating networks and coalitions of common interest; promotion of media and educational campaigns to raise public 1 Baker SP, O'Neill B, Ginsburg MJ, & Guohua Li: The injury fact book 2nd edition. Lexington, New York, Oxford University Press, 1992. 2 L. Cohen et al.: Journal of Safety Research 34 (2003), 473-483. 3 Injuries in the WHO European region 2005:1. 4 Injury Surveillance Guidelines, 2001:1.

9 awareness. The public health approach to injury control includes: identification of the problem; identification of risk factors and target groups; implementation of countermeasures; evaluation of effectiveness; and dissemination of results. In order to prevent injuries effectively, accurate information on the number of injuries, their types and victims is needed. This kind of information gives an indication on the seriousness of the injury problem so that the cases where prevention measures are mostly needed can be identified. Injury data is also needed for evaluating the effectiveness of injury prevention practices. Injury prevention can aim to decrease just a single type of injury, such as drowning, or it can target all types of injuries. Likewise, injury prevention can use just one method (e.g. promote the use of life jackets in order to prevent drowning), several methods or a comprehensive approach. Those that support a comprehensive approach argue that behaviour and objects within any environment are interrelated and can strongly influence one another. Therefore, to address one and not the other results in a less effective approach. 5 Injury prevention can also target specific groups of the population. As an example, we can take the injuries among the elderly, which are becoming a growing concern for health and social care in several countries. The main reason is that the proportion of the aged population is growing rapidly. It is estimated that the proportion of people over the age of 65 will increase up to 20% of the population in most countries of the European Union. The results show that, in all regions, an elderly person having a fall accident at home is a major public health problem. Therefore, the prevention of these accidents should be prioritised. Because fall injuries are often severe, prevention results in large economical benefits for the society. Fall accidents also greatly deteriorate the quality of life among the elderly. 1.3. Definition of Safety and Safety Promotion According to Maslow's Needs Theory, safety is one of the fundamental needs for human beings, just like physiological needs are. For example, WHO and UN strongly support the view that safety is a fundamental human right. WHO has defined safety "as a state in which hazards and conditions leading to physical, psychological or material harm are controlled in order to preserve the health and well-being of individuals and the community. It is an essential resource for everyday life that an individual and a community need in order to realize their aspirations". 6 Safety is a dynamic state resulting of a complex process, in which people interact with their environment, including not only physical, but also social, cultural, political, technological, economical and organizational environments. It is important to note that safety is more than the absence of violent events or injuries. However, at the same time safety cannot mean a total absence of hazards. There are two dimensions to safety - objective and subjective. Objective safety can be assessed by behavioural and environmental objective parameters, whereas subjective safety refers to the feeling of safety of the population. Both of these dimensions can influence each other in positive or negative ways, and they should therefore be taken into account when aiming to improve safety. In order to develop international consensus on the concepts of safety and safety promotion, WHO and its Collaborating Centres for Safety Promotion and Injury Prevention and the WHO Collaborating Centre on Community Safety Promotion produced "The Quebec Document", which includes the above-mentioned definition of safety, as well as the four basic conditions for safety. According to this definition, attaining an optimum level of safety requires individuals, communities, governments and other actors to create and maintain the following conditions, whichever setting is considered: 1. A climate of social cohesion and peace as well as of equity, protecting human rights and freedoms, at a family, local, national or international level. 2. The prevention and control of injuries and other consequences or harms caused by accidents. 3. The respect of the values and the physical, material and psychological integrity of the individuals. 4. The provision of effective preventive, control and rehabilitation measures to ensure the presence of the three previous conditions. 7 5 L. Cohen et al.: Journal of Safety Research 34 (2003), 473-483. 6 Safety and Safety Promotion, Conceptual and Operational Aspects, 1998:7. 7 Safety and Safety Promotion, Conceptual and Operational Aspects, 1998:6.

10 Safety promotion can be defined as the process, applied at a local, national and international level by individuals, communities, governments and other actors, such as NGOs and private enterprises, to develop and sustain safety. This process includes all efforts agreed upon to modify the environment (physical, social, technological, political, economical and organizational), structures as well as attitudes and behaviour related to safety. Safety promotion can have a top-down or a bottom-up approach. In the first case, the governmental authorities are the main actors who also attempt to influence local actors, whereas in bottom-up approach, like the Safe Community Concept, the initiative comes from local actors. At least two types of processes can be used to promote safety in a community: the problem-oriented and the setting-oriented process. The problem-oriented process is the search for specific solutions to problems, considered one at a time. The setting-oriented process consists above all of the assessment of the safety problems of a specific setting in a global perspective, and in the identification of an integrated set of solutions aimed at improving the safety level of the population. These two processes, although quite distinct, are both complementary and essential. One huge challenge to all safety promotion and injury prevention is caused by the fact that its actions are a series of "nonevents", which are always less evident than the needs for the treatment of an injury, e.g. a broken hip, are. Therefore, there is a need for safety promotion and injury prevention programmes to make their actions and benefits "visible". This includes for example showing by both human and economic measures how much resources and how many people are saved from injury. 8 An effective safety promotion programme should always have a clear description of the current situation, including safety and injury patterns, as well as identification and assessment of risks. 1.4. Links Between Safety and Health The 1948 Constitution of the World Health Organisation (WHO) defined health as a state of complete physical, mental and social wellbeing. This definition means that health is influenced by almost everything around us. Health promotion strategies are not limited to a specific health problem, nor to a specific set of behaviours. Health promotion, and the associated efforts put into education, community development, policy, legislation and regulation, are equally valid for the prevention of communicable diseases, injury and violence, and mental problems, as they are for the prevention of non-communicable diseases. Safety promotion programmes have introduced a novel approach to public health, according to which safety is a pre-requisite to the maintenance and improvement of the well-being and health of the population. The Swedish focus on the community approach to the promotion of safety is in agreement with the WHO philosophy of health promotion. However, from the safety promotion perspective, safety should be seen as an essential component of health, and viewed as an essential component of health activity at the community level. From the health promotion perspective, safety promotion is a part of its working sphere, but not the only one, nor any more important than the other areas are. According to some views, health promotion approach is more focused on individuals whereas safety promotion is more focused on the environment, but when their methods are studied they seem to overlap in many cases. Just like safety promotion, also health promotion has developed "bottom-up" approaches, most notably the WHO Healthy Cities Network, including the European National Networks of Healthy Cities that links more than 11 000 cities across Europe in 26 countries. There is also the Baltic Region Healthy Cities Association that involves all the countries in the BSR. By June 2005, there were eight designated Healthy Cities, three cities having their application in process, and five cities having observer status in the BSR region. Some cities in the BSR countries have been designated both as a Safe Community and as a Healthy City. 1.5. Links Between Safety Promotion and Civil Protection Within the EU, civil protection has been defined as "the protection of persons, environment and property in the event of a natural or a technological disaster". The EU has divided the types of disasters from the point of view of civil protection in the following way: 8 Welander, Svanström & Ekman, 2000:8.

11 natural disasters (e.g. avalanches, earthquakes, floods, forest fires and volcanic eruptions); civil protection aspects of technological disasters, including chemical and industrial accidents, transportation and storage of chemicals, transportation accidents and nuclear emergencies; and environmental aspects of disasters. 9 Recently, also prevention and preparedness measures against terrorist attacks have been included. Moreover, at the Feira European Council, civil protection was defined as one of the four priority areas of civilian crisis management that the EU will develop. As such, civil protection can be seen as a part of a wider concept of crisis management, which includes both civilian and military aspects. However, it is important to note that within the EU organization, civil protection is a part of the European Commission's Environmental Directorate, whereas civilian crisis management belongs to the EC's Directorate General of External Relations. At the EU level, there has not been any considerable linkage between civil protection and injury prevention & safety promotion programmes or practices, of which injury prevention belongs to EC's Health and Consumer Protection Directorate. However, there have been some efforts to create connections between civil protection professionals and injury prevention and safety promotion experts. At the international level, this has been done in injury prevention and safety promotion conferences, where the role of the rescue services has been included as one the conference themes. This was the case e.g. during the 7th Conference on Injury Prevention and Safety Promotion, held in June 2004 in Vienna, Austria, and during the 14th International Safe Community Conference, held in June 2005 in Bergen, Norway. At the national level, the forerunner in the integration of these two fields has been Sweden, where the Swedish Rescue Services Agency has now the main responsibility of injury prevention work in the country. In some other BSR countries the authorities of these sectors co-operate regularly and have had joint efforts, e.g. in preparing safety promotion campaigns. The similarities between injury prevention, safety promotion and civil protection are profound. All address the risks in societies and aim to limit their occurrence and effects. Injury prevention addresses risks that occur fairly often in societies but whose consequences are considered to be less severe to the society, whereas civil protection usually addresses risks that occur less often but have more serious consequences. 1.6. "Addressing All Kinds of Risks", Reasons to Promote Co-operation Between Different Sectors The comprehensive approach has gained more support both in the safety promotion field and in civil protection. In civil protection, more emphasis has been put to prevention and preparedness measures, and in many countries this is already considered as the priority area of work for rescue services. In order to do prevention and preparedness work effectively, civil protection authorities need good co-operation with the other actors, such as public health authorities and community planners. In the safety promotion sector, safety research and practical safety management have traditionally been separate. Traffic safety, work safety, leisure safety, etc. have been promoted in segmented operations. Even some special types of accidents, such as drowning have had their special experts. However, an individual is usually exposed to most segments of safety every day. Some accident types are also similar in different sectors. The lack of cooperation between safety segments can lead to a loss of resources. Time and intelligence is wasted when several specialists target the same phenomenon and try to understand it, "inventing the wheel again". Therefore, a more comprehensive approach within the injury prevention and safety promotion field would be beneficial, as would an approach that includes or cooperates with the rescue service authorities. There are some institutional constraints that can be identified, which are making it more challenging to include safe community initiatives to civil protection. These constraints include the fact that in many countries civil protection is split between different governmental agencies, like health and safety agencies, disaster management agencies or environmental agencies, creating a barrier to an integrated approach to emergency management. Another fact is that, in the field of civil protection the response to accidents has tradi- 9 Vade-mecum of Civil Protection, 1999:17.

12 tionally been seen as a priority area rather than a prevention measure. However, a more integrated approach would be beneficial, as any actions that aim to address the risks in the current society can only be effective if they mobilize many different sectors of society. 2. The Safe Community Concept 2.1. Origins of the Safe Community Programme and Its Development The idea of "A Safe Community" was launched as a Swedish initiative formally in the First World Conference on Accident and Injury Prevention in Stockholm in 1989. However, the origins of the model stretch further back than that. Local injury prevention programmes in the Swedish communities of Falköping, Lidköping and Motala - developed during the 1970s and 1980s - have played an important role in the development of the Safe Community model. However, it should be noted that there were also other communitybased injury prevention models developed at the same time in other countries, which have also influenced the development of the safe community model. From the policy-making viewpoint, the Safe Community model has its roots in the development of health policy movements, such as WHO's Health for All Strategy. The Stockholm Manifesto for all Safe Communities, the fundamental document for Safe Community development, adopted by resolution at the 1989 conference, states: "All human beings have an equal right to health and safety". This principle is the fundamental premise of WHO's Health for All Strategy and the WHO Global Programme for Accident Prevention and Injury Control. Other important documents that have followed the manifesto are: The Sundsvall Statement on Supportive Environments for Health from 1991; The Melbourne Declaration on Injury Prevention and Control, formulated at the Third International Conference on Injury Prevention and Control in 1996; The Quebec Document 10, formulated in 1998, which concentrates on the conceptual and operational aspects of safety and safety promotion; and The Dhaka Communiqué, adopted as a conclusion of the 9 th International Safe Community Conference in 2000. Since the launch of the idea, the Safe Community model has spread around the world. The current Safe Community Network, with 85 member communities and 11 Affiliate Safe Community Support Centres, covers most of the continents and is constantly expanding. The number of designated Safe Communities has increased rapidly, as in the beginning of the year 2001 only 56 communities had been designated. So far, the most active year was 2002, when nine communities were designated. Re-designations are not included in these figures. Members of the Safe Community Network exchange knowledge, experiences and research findings. By now the Safe Community initiative is also a part of WHO's global safety promotion and injury prevention programme. 2.2. The Current Situation of the Safe Community Network In June 2005, there were 85 designated Safe Communities in 16 countries: Australia, Austria, Canada, China, the Czech Republic, Denmark, Estonia, Finland, the Netherlands, New Zealand, Norway, South Africa, South Korea, Sweden, the United Kingdom and the United States. 11 For a long time, the biggest number of Safe Communities, 14, was understandably enough in Sweden where the programme originates, but in 2005 Norway took the lead with 15 Safe Communities. Also Australia has a considerable number of Safe Communities, 11. The size of the population in Safe Communities ranges from 2000 to 2 million inhabitants. Altogether, over 11 million people live in designated Safe Communities. The novelty of the Safe Community programme is that it is an injury prevention and safety promotion programme, in which the leading role is played by the community itself. 12 The idea is to have everyone in a community involved with the programme, or in practice, a strong enough group to make the programme successful. This obviously means that the approach is multisectoral. The Safe Community model is based on the premise that in order to develop safe communities, local situations and resources, as well as the important cultural and socio-economic determinants of the injury, must be under- 10 http://www.inspq.qc.ca/pdf/publications/150_securitypromotion.pdf 11 http://www.phs.ki.se/csp 12 Schelp 1987, Jansson 1988, Lindqvist 1992, Ytterstad 1995, Svanström et al. 1996, Ekman 1996, Rahman 1997.

13 stood and taken into account. This is arguably one of the strengths of the Safe Community model, as, consequently, it is possible to adapt it to the diverse cultural and socio-economic circumstances of the communities. The developers of the Safe Community model also believe that those people that are directly involved with the injury risks have the best knowledge about them, based on their experiences and observations. On the other hand, since accidents and injuries almost always happen at the local level, the municipalities' capacities to manage these incidents should be strengthened. It is also thought that it is easier to engage people to local level safety promotion programmes that include familiar places, situations and problems. The basic idea is to build on the structures (social, political and economical) and organizations available in any local district. The safe community initiative recommends actions that create supportive environments; strengthens community action; broadens public services; and formulates public policies for safety. The Safe Community model has often been described as a bottom-up approach. It has often been argued that bottom-up approach should be preferred to top-down approach, because the latter model poses the risk of misunderstanding the real needs of the population. This can lead to a situation where a safety promotion programme is ineffective because people do not care about it and do not want to engage themselves to it. It has been argued that a bottom-up approach can be more effective as people have opportunities to express their opinions, which can create a stronger commitment to the process. In many cases, people also have a better chance to influence things on the municipal level than on the national level. However, the situation is not that simple, because in some countries, e.g. in Sweden and Norway, the national level support for the Safe Community programme has been considerable. Moreover, in some societies, the amount of the activities that can be done at the local level without official approval of the higher level can be rather limited. The developers of the programme argue that in these cases, it might be necessary to get the national level commitment to the programme before work at the local level is started. 13 The centre that has the main responsibility for the development of the Safe Community model is the WHO Collaborating Centre on Community Safety Promotion, situated at the Karolinska Institutet, Department of Public Health Sciences, Division of Social Medicine, Stockholm, Sweden. The role of the WHO Collaborating Centre is to coordinate a worldwide network of Safe Communities and Affiliate Safe Community Support Centres, to develop indicators for Safe Communities and to organize training courses, conferences and seminars in safety promotion. A Safe Community can be a municipality, a city, a district of a city, or a county working with safety promotion, as well as with injury, violence and suicide prevention. In order to be designated as a Safe Community, a community needs to fulfil the following six indicators that were adopted in 2002 (originally there were 12 criteria): 1. An infrastructure based on partnership and collaborations, governed by a cross-sectoral group that is responsible for safety promotion in the community; 2. Long-term, sustainable programme covering both genders and all ages, environments and situations; 3. Programmes that target high-risk groups and environments, and programmes that promote safety for vulnerable groups; 4. Programmes that document the frequency and causes of injuries; 5. Evaluation measures to assess these programmes, processes and the effects of change; 6. Ongoing participation in national and international Safe Community Networks. 14 Any community fulfilling the criteria can make an application to the WHO Collaborating Centre on Community Safety Promotion at the Karolinska Institutet and if it is accepted, an agreement is signed between the WHO Collaborating Centre and the community. The application process includes also a site visit made by the representative of the WHO Collaborating Centre. The applying community has to cover the costs of this visit, the designation, as well as a 900 administration fee. A Safe Community designation can be taken away, as has happened in some cases in Denmark, France and Thailand. All Safe Communities have to apply re-designation after ten years of their first designation. Examples of re-designated Safe Communities are Harstad in Norway, and Motala, Lidköping and Falköping in Sweden. 13 Welander, Svanström & Ekman 2004. 14 http://www.phs.ki.se/csp/who_safe_communities_indicators_en.htm

14 This illustrates the never-ending nature of Safe Community work. It should be noted that the indicators are relative in nature, and therefore it is rather difficult to compare the aims of the different Safe Communities. In addition to Safe Communities, the WHO Collaborating Centre on Community Safety Promotion also designates Affiliate Safe Community Support Centres. An organization or university can be appointed if it fulfils the ten indicators set by the WHO Collaborating Centre. 15 The first centre was designated in 1996. There are currently altogether 11 Affiliate Safe Community Support Centres: two in Australia and Canada, and one each in Austria, Bangladesh, China, the Czech Republic, Korea, New Zealand and South Africa. There are several different "sectors" in the Safe Community programme, and these sectors also vary from community to community. Usually, children and elderly people are among the priority groups in the Safe Community work as they are considered to be the most vulnerable groups. The six general indicators have been complemented by special sectoral indicators, such as Safe Schools, Safe Sports, Safe Housing, Safe Children, Safe Elderly, Safe Homes, Safe Workplaces, Safe Public Places and Safe Waters. It has been argued that communities have managed to decrease their injury rate up to 20-30% by using the Safe Community programme. The Safe Community programme started as an unintentional injury prevention programme, but it has widened its scope since to cover also intentional injuries, like suicide, violence and crime. This is a considerable difference to many other traditional injury and accident prevention programmes, which do not include violence or suicides in their subject matter, since they argue that these issues need different means of prevention. One of the most important activities of the Safe Community network is the annually organized International Conference on Safe Communities. The 14th Conference was held in Bergen, Norway in June 2005. The main theme of the Conference was "Violence Prevention in Creating Safe Communities". It is worth noticing that one of the topics was "The Role of Rescue Services in Creating Safe Communities", which shows the raising awareness of the importance of integrating the rescue services' work with other injury prevention and safety promotion work. There are also several regional conferences organized world-wide, of which those involving the BSR countries will be discussed in the following chapter. The 1 st Safe Community Conference on Injury Surveillance will be held in September 2005 in Trondheim, Norway. There have been also many travelling seminars organized in various countries. Finally, it should be noted that the term safe community is not legally "owned" or "controlled" by any one group, so it is used and interpreted in a number of ways by various communities and countries around the world, which do not necessarily follow the criteria set by the WHO Collaborating Centre on Community Safety Promotion. For example, in Canada there are two models under which a community can apply to be officially designated a Safe Community: the WHO Collaborating Centre on Community Safety Promotion's Safe Community Network model and the Safe Communities' Foundation model, which works at the national level. Furthermore, many communities around the world might be working to improve their community safety and do this work effectively even if these communities are not part of, nor are seeking to be part of these official Safe Community networks. In this context, Safe Communities could be described as a management model for addressing safety issues at the community level. 3. The Safe Community Programme in the Baltic Sea Region 3.1. Regional Activities and Co-operation The European Safe Community Network (ESCON) has been playing a key role in expanding the Safe Community movement to cover the whole Europe. ESCON was started during a network meeting organized by the Karolinska Institutet and Falköping Municipality in Sweden in 1997. Representatives of 21 countries, both from national and local level, have accepted the working documents of the Network, elected the Steering Committee and 15 See the criteria in detail: http://www.phs.ki.se/csp/who_affiliate_centers_en.htm

15 the Secretariat. The Network was established to promote the cause of injury prevention by enhancing: co-operation between potential partners at community, regional, national and European level; and the exchange of knowledge and experiences in safety promotion and injury prevention. 16 Currently (June 2005), there are 41 designated Safe Communities in Europe, of which 35 are situated in the BSR-countries (Norway included). Overall, more than one third of all designated Safe Communities are situated in the BSR countries. One of the most important Safe Community activities in the BSR has been the series of Nordic Safe Community Conferences. The first one was organized in Skövde, Sweden in 1996, and it was followed by conferences in Norway in 1997, Iceland in 1999, Denmark in 2001 and the latest in Finland in autumn 2003, which was the first conference to which the Baltic countries were also invited. The conferences have included reviews on good experiences of national policy development and safety community work in all Nordic and Baltic countries, as well as in the European Union. In the latest conference, there were almost 200 participants, mainly from the Nordic and Baltic countries, but also from Africa, North America and Australia. The 6 th Nordic Safe Community Conference will be organised in Karlstad, Sweden, in November 2005. The main theme of the conference will be community empowerment. There has also been regular co-operation between the designated Safe Communities in the BSR countries, as well as between them and those communities that have showed interest to start the Safe Community programme. Other important activities in the BSR have included: - 1997 Meeting "Safe Communities: the Application to Societies in Transition", in Estonia - 1998 "Latvian-Swedish Injury Prevention Research Conference & Safe Communities Seminars" - 2000 "First Nordic-Baltic Research Course on Injury Prevention and Safety Promotion", in Latvia - 2002 "Second Advanced Nordic-Baltic Course on Safety Promotion and Injury Prevention", in Estonia - 2003 "EUROBALTIC Workshop on Establishing Policies on Safe Community Programmes", in Sweden - 2004 "EUROBALTIC Workshop on Safe Community - Safe Industry", in Sweden - 2005 "EUROBALTIC Workshop on a Safer Work Environment in Agriculture", in Sweden There have also been activities concerning specific issues on injury prevention and safety promotion, such as "The 1 st International Forum on Traffic Safety in Baltic States and European Union", which was organized in April 2004 in Riga, Latvia. 3.2. Other Injury Prevention and Safety Promotion Activities Involving the BSR Countries At the global level, the most important actor in the field of injury prevention and safety promotion is WHO, in whose programmes and other activities all the BSR countries take part. One of WHO's most important activities is the World Conference on Injury Prevention and Safety Promotion, which is organized every other year. The conference has been organized seven times so far. The latest conference was organized in June 2004 in Austria. These conferences handle a wide range of cross-sectoral issues. For example, the latest Conference had the following themes: violence prevention, suicide prevention, road safety, work safety & health, child & elderly safety, safety at home & institutions, sports & leisure time safety, product safety, trauma management, disaster & terrorism preparedness, civil protection and safe communities. At the European level, the European Union has its own Injury Prevention Programme, which is based on two activities: the collection of data on injuries and accidents in the member states; and on epidemiological projects, which are based on the above data and/or the collection of additional information. The Injury Prevention Programme of the European Commission follows the European Home and Leisure Surveillance System (EHLASS). EHLASS was designed more than ten years ago by the European Commission to support its member states in the collection of data about home and leisure accidents for themselves. This 16 www.safecommunity.net/escon

16 resulted in the use of different collection methods, different classifications and databases. The Injury Prevention Programme (IPP) was created in 1999 to increase the European added value. It ended with the adoption of the New Public Health Programme in 2002. One of the main goals was to create a common database (ISS - Injury Surveillance System within EUPHIN - European Public Health Information Network) with quality data collected using a common classification and comparable methods. Apart from the data collection projects, epidemiological projects were funded. The injury prevention network and a co-ordinating secretariat were funded and a permanent qualitative evaluation was performed. EU's injury prevention continues now under the New Public Health Programme for 2003-2008. 17 The European Commission and the WHO Regional Office for Europe are organizing a pre-event to the 1st European Conference on Injury Prevention and Safety Promotion in October 2005 in Greece. There are also many other international and regional organizations in the field of injury prevention and safety promotion to which countries from the BSR belong, such as: - European Consumer Safety Association (ECOSA) - European Network for Workplace Health Promotion - European Agency for Safety and Health at Work - Nordic Medico-Statistical Committee (NOMESCO) - European Association of Poison Centres and Clinical Toxicology (EAPCCT) - Megapoles - a public health network for capital cities/regions in the EU. Further, the representatives from these countries have taken part in several international and regional activities, as well. In the field of research in injury prevention and safety promotion, one example of collaboration is the series of Nordic Research Conferences on Safety, of which the 16 th one was held in Denmark in June 2005. Another example of research activities are the courses organized by the Karolinska Institutet in Stockholm, Sweden. The first Ph.D. level course on the issue took place in January 2005. 3.3. The Current Situation in Injury Prevention and Safety Promotion in the BSR Countries Denmark General information: Population: 5,364,000 (WHO, The World Health Report 2003) GDP per capita (Intl $, 2002): 29,227 (WHO) Life expectancy at birth: male 75 years, female 80 years (WHO) Injury statistics and trends & injury registration: In Denmark, there are several different standardized systems to document the frequency and causes of injury. The Danish National Board of Health is responsible for registering the causes of death. All deaths are reported to this register, from which it is possible to extract information, such as the circumstances and causes of death. The Danish National Board of Health is also responsible for the National Patient Register, which is a mandatory and standardized system of reporting all patients that have received treatment in hospitals. All patient visits to accident and emergency departments are registered using the Scandinavian accident classification system NOMESCO. This involves the registration of a location code (where the injury was sustained), an injury mechanism code (what caused the injury), and an activity code (what the patient was doing when the injury was sustained). 18 The individual general practitioners set their own standards for the registration of patient visits. The regulations for this practice are laid down in a statutory order of the Danish National Board of Health. General practitioners are not obliged to pass on registered information about their patients to other doctors or authorities, but work-related accidents involving personal injury must be reported to the Danish Working Environment Service. The police forces register all major traffic and other accidents. At the Odense University Hospital, there is a long tradition for the extended registration of injuries treated in the accident and emergency department. The Accident Analysis Group is the main key source of injury epidemiology in Denmark. All the hospitals in 17 http://europa.eu.int/comm/health/ph_determinants/environment/ipp/ipp_en.htm 18 Velje Safe Community Application. http://www.phs.ki.se/csp.