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Greenberg-Seth J, Hemenway DA, Gallagher SS, Ross JB, Lissy KS. Am. J. Public Health 2004; 94(12): 2047-2048.


Harvard School of Public Health, 677 Hunting-ton Ave, 3rd Floor, Boston, MA 02115 (e-mail:


(Copyright © 2004, American Public Health Association)






We agree with the points raised by Hyder. It is important to design programs that effectively communicate injury prevention messages to people with lower incomes, limited literacy, or limited access to media. We think that community participation in program design and evaluation is a key to accomplishing this.

Any intervention, domestic or abroad, in low- or high-income communities, should begin with formative evaluation to determine literacy needs, community resources, and credible and accessible sources of information. Involving members of the population one is trying to reach is critical. Proven strategies should be modified or adapted for different settings or countries and evaluated in those settings.

In our study, the goal was to increase child rear seating in conjunction with proper restraint use by reinforcing educational messages with incentives for positive behavior. We made special attempts to reach lower-income segments of the population through collaboration with existing community organizations, including those that primarily serve low-income residents. The community task force formulated much of the intervention design. Focus groups and interviews with members of the target population were used to test for appropriateness of materials and distribution channels.

The greater improvement at observation sites in higher-income areas was unexpected, given the level of community participation and our formative research. We are unable to assess whether the difference in impact is because our message did not reach as many of the families we observed in lower-income areas or because the families we observed in higher-income areas were more likely to change their behavior.

However, even if the direct impact of an intervention is greater in higher-income areas, programs that take a participatory approach to design and implementation can have indirect or unanticipated benefits in addition to changing the intended behavior. Organizing the community to address a specific issue allows people and organizations to collaborate in new ways. Building these relationships can strengthen the communityâ??s capacity for addressing other issues. Through surveys and informal observations, we learned that members of our community task force began to extend their relationships beyond the project and were collaborating on other injury prevention, health promotion, and community-building projects.

We think that a participatory approach can be effective regardless of the country in which the intervention takes place, the target audience, or the injury topic being addressed.


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