Dale Hanson

Leif Svanström, born in Västervik, Sweden, on 30 October 1943, was a big man in physical and intellectual stature, persona and impact. Leif trained at Lund University, obtaining a BA in Genetics and Society in 1966, an MD in Preventative Medicine in 1972 and a PhD in Accident Prevention and Injury Control in 1973. He was appointed associate professor in the Department of Social Science at Lund University in 1978 and subsequently professor of Social Medicine at the Karolinska Institutet, Stockholm, Sweden, in 1980. The research group he led generated over 30 doctorate dissertations, 6 professors, more than 1000 papers and 20 textbooks. In 1989, he chaired the inaugural World Conference on Accident and Injury Prevention in Stockholm, Sweden, a conference that remains the premier international forum for injury prevention and safety promotion. Leif championed place-based, analytical, interdisciplinary, intersectoral, real-world injury prevention and safety promotion practice, culminating in the development of the Safe Community Model that spread internationally and ultimately created a network of over 430 designated International Safe Communities, with a population footprint of over 100 million people. For all these laudable achievements, it was Leif’s charismatic ability to inspire, teach, support, motivate and sustain those around him that produced his profound impact on the practice of injury prevention and safety promotion throughout the world. Leif Svanström passed away in Sweden on 29 January 2023 at age 79.

Background: Medical boards and healthcare providers internationally are coming under increasing pressure to attract international medical graduates (IMGs) and overseas trained doctors (OTDs) to cope with predicted general practice (GP) doctor shortages. Various pathways to registration are made available for this purpose. There is very little understanding of the effects of different training pathways to licensing and registration on the ability of IMGs and OTDs, as well as locally trained doctors, to acquire the desirable professional skills deemed necessary for working effectively in the primary care sector. Methods: Feedback from patients was collected at the end of their scheduled consultation with their doctor using a questionnaire consisting of 13 Likert scale items that asked them to rate their experience of the consultation. Feedback was obtained for doctors going through the Royal Australian College of General Practice (RACGP) Practice Experience Program (PEP) and the Australian General Practice Training Program (AGPT), with the former intended primarily for IMGs and OTDs, and the latter for local medical graduates including from New Zealand. Patient feedback was also obtained for patients visiting already Fellowed and experienced GPs for comparative purposes, resulting in data for three groups of doctors (two trainee, one already Fellowed). Rater consistency and agreement measures, analysis of variance, principal component analysis, t-tests and psychometric network analysis were undertaken between and within groups to identify similarities and differences in patient experience and professionalism of doctors. Results: There was a small but significant difference in average patient raw scores given to PEP and AGPT doctors (90.25, 90.97%), with the highest scores for ‘Respect shown’ (92.24, 93.15%) and the lowest for ‘Reassurance’ 89.38, 89.84%). Male patients gave lower scores (89.56%) than female patients (91.23%) for both groups of doctors. In comparison, patients gave experienced GPs an average 91.38% score, with male patients giving a lower average score than female patients (90.62, 91.93%). Two components were found in the patient data (interpersonal communication, caring/empathy) that account for over 80% of the variance. When patient scores were aggregated by doctor, the average PEP and AGPT doctor scores received were 90.27 and 90.99%, in comparison to the average experienced GP score of 91.43%. Network analysis revealed differences in the connectedness of items between these two groups as well as in comparison with experienced GPs, suggesting that PEP doctors’ skills are less cohesively developed in the areas of listening ability, explaining and providing reassurance. Conclusions: The small but statistically significant differences between doctor groups reported in this preliminary study are supplemented by percentile analysis, network analysis and principal component analysis to identify areas for further exploration and study. There is scope for improving the integration of interpersonal communication skills of GPs in Training with their caring and empathy skills, when compared with experienced GPs as a benchmark. Suggestions are made for enhancing professional skills from a patients’ perspective in future training programs.

Multisource feedback is an evidence-based and validated tool used to provide clinicians, including those in training, feedback on their professional and interpersonal skills. Multisource feedback is mandatory for participants in the Royal Australian College of General Practitioners Practice Experience Program and for some Australian General Practice Training Registrars. Given the recency of the Practice Experience Program, there are currently no benchmarks available for comparison within the program and to other comparable cohorts including doctors in the Australian General Practice Training program. The aim of this study is to evaluate and compare colleague feedback within and across General Practice trainee cohorts. Colleague feedback, from multisource feedback of Practice Experience Program participants and Australian General Practice Training Registrars, collected between January 2018 and April 2020, was compared to identify similarities and differences. Analyses entailed descriptive statistics, between and within groups rater consistency and agreement measures, principal component analysis, t-tests, analysis of variance, and psychometric network analysis. Colleague ratings of Practice Experience Program participants (overall average 88.58%) were lower than for Registrars (89.08%), although this difference was not significant. ‘Communication with patients’ was rated significantly lower for Practice Experience Program participants (2.13%) while this group was rated significantly better for their ‘Ability to say no’ (1.78%). Psychometric network analyses showed stronger linkages between items making up the behavioural component (compared to the items of the performance and self-management components, as found by principal component analysis) for Practice Experience Program participants as compared to Registrars. Practice Experience Program participants were stronger in clinical knowledge and skills as well as confidentiality, while Registrars were stronger in communicating with patients, managing their own stress, and in their management and leadership skills. The multisource feedback scores of doctors undertaking the Practice Experience Program suggests that, while all mean values are ‘very good’ to ‘excellent’, there are areas for improvement. The linkages between skills suggests that Practice Experience Program doctors’ skills are somewhat isolated and have yet to fully synthesise. We now have a better understanding of how different groups of General Practitioners in training compare with respect to professional and interpersonal skills. Based on the demonstrated differences, the Practice Experience Program might benefit from the addition of educational activities to target the less developed skills.

Background: A number of international safe communities are displaying increasing interest in the United Nations Sustainable Development Goals (UNSDG). The International Safe Communities Certifying Centre is seeking to establish formal relations with the World Health Organization (WHO). Purpose: A formal review of the UNSDG and WHO General Program of Work 13 – 2019 to 2023 (WHO GPW13) alignment with the international Safe Communities indicators. Methods: UNSDGs were formally reviewed by 4 senior ISCCC certifiers and ranked in terms alignment with International Safe Communities Indicators. Results: While injury imposes a considerable cost burden on communities, safety is a critical precondition necessary for the attainment of the productive physical, physical and social environments that communities require to achieve their full potential. Safety provides a dynamic leverage point for communities to achieve their aspiration for sustainable development. There is very strong alignment between the UNSDGs and the International Safe Community Indicators The holistic understanding of injury prevention and safety promotion adopted by the safe communities movement supports the WHO vision to “Promote health, keep the world safe and serve the vulnerable” articulated in its 13th General Program of Work (GPW): 2019 to 2023. Based on the analysis the ISCCC board has identified 7 domains of injury prevention and safety promotion practice that are of high strategic importance8: • Disaster preparedness • Prevention of Road Traffic Injuries • Prevention of Violence against Women • Prevention Violence against Children • Suicide prevention • Falls prevention • Prevention of workplace injury. All new designation applications submitted after the 1st of July 2019 must provide statistical information regarding the incidence of these issues and to describe how they are addressed in their community. Conclusion: The International Safe Community movement embraces a whole of system (ecological) definition of injury prevention and safety promotion that aligns easily with the United Nations Sustainable Development Goals (UNSDG) and the WHO General Program of Work 13, 2019 to 2023 (WHO GPW13).

Background: Designing a safety promotion programs that have significant impact on the wellbeing of your community is about finding creative solutions for the tension between visionary dreams and practical, evidence-informed solutions: • Nothing will be achieved unless you have the vision to imagine a better reality for ourselves, our family, our friends and our community • Nothing can be achieved unless you have the pragmatism and commitment to seek out achievable evidence informed effective solutions1. To achieve population level reductions in injury you need to GET REAL! Purpose: The ISCCC commissioned a guideline to assist communities addressing Indicator 4 - Programs that are based on available evidence - in their designation application. Methods: Review of the international literature on translation of research into practice Results: Millions of lives could be saved if we just applied what is already known. This is the business of Indicator 4. Effective public health programs are the logical consequence of sound evidence. To implement an effective community-based safety promotion and injury prevention program three types of experts are required 1. Researchers (experts in what to do) 2. Politicians, administrators and practitioners (experts in how to do it) 3. Members of the target community (experts in what will work for them) four types of knowledge / evidence are required: 1. Evidence from a community’s own research and surveillance systems (Indicator 6) 2. Evidence about common types of injury and their causes 3. Evidence-based practice – evidence about what has been shown to work under research conditions 4. Practice based evidence – evidence about what has been shown to work in real world conditions. Conclusion: Accessing, interpreting and applying sound evidence is critical to the success of a safe community program.

Background: While project sustainability is a mandatory piece of politically correct rhetoric, it is less often achieved. Mackay Safe Communities (MSC) was developed using a capacity building model that consciously attempted to design sustainability into the network. This study sought to analyze the sustainability of MSC by tracking the exchange of resources using Social Network Analysis (SNA). Methods: A snowballing methodology was used to identify the MSC and its external support network (ESN). Respondents were asked to identify the type and amount of resources they shared with other network partners. Results: The study identified 168 members of the MSC and its ESN. Thirty-five percent of relationships did not share any resources; 47% shared in-kind resources, 54% shared human resources and 15% shared financial resources. In 2004 MSC accessed an estimated 6.5 full time staff equivalents and $0.9 million Australian dollars. However, these resources were largely accessed through, and controlled by, the ESN. Conclusion: MSC was rich in social resources, but considerable in-kind, human and financial resources were accessed through its ESN. The bridging relationships that connected MSC to its ESN, more than half of which were maintained by six broker network facilitators, were the critical social asset required to access resources and thereby sustain network productivity. MWSC is an open network. Open social networks can never be totally self-sufficient. The ongoing productivity of a social network is dependent on its capacity to develop and maintain productive links with external partners.

Background: The International Safe Communities movement was established in 1986, and since that time has developed into an international collaborative network comprised of the WHO CCCSP/ ISCCC, regional and national safe community organizations, support centers and communities. Purpose to review the outcomes of communities who have achieved designation as an international safe community over the 32-year period from 1986 to 2018. Methods: An audit of the ISCCC database and website was undertaken. Any inconsistencies were checked for accuracy against the original designation application. Results: Since the safe community movement began in 1998 four hundred and three International Safe Communities have been designated. Data was available for analysis regarding 361 communities. Thirty-eight communities, all designated prior to 2006, had been removed from the data base prior to this data being handed over to the ISCCC. The data set is complete from 2006 onwards. The program has a high reach, 86 million people have been served by a safe community program that has achieved International Safe Community Designation on at least one occasion (1.1% of the world population). Forty-nine millions of these are served by safe community programs whose certification remains active. In 2018 there were 39 certifications (13 designations and 26 redesignations), covering a population of 7.1 million people. One hundred and sixty-one (40%) of the original 403 communities have maintained a safe community certification. Two hundred and forty-four (68%) communities only sought initial designation, 92 (25%) were designated twice, 22 (6%) were designated three times and 3 (1%) were designated four times. International Safe Communities vary considerably in size from the smallest with a population of 1,000 inhabitants to the largest of 12 million. However, the distribution is skewed towards smaller communities (5th percentile = 6,000, a median of 90,000, a mean of 240,000 and a 95th percentile of 700,000. Conclusion: The International Safe Community movement has accomplished remarkable growth in the 30 years since it began in Sweden in the late 1980s. The program has achieved high reach. Four hundred and three communities have been designated by the end of 2018 with a population footprint of 86 million people.

Mackay Whitsunday Safe Community (MWSC) was established in 2000 in response to high rates of injury observed in the region. MWSC assumed an ecological perspective, incorporating targeted safety promotion campaigns reinforced by supportive environments and policy. By involving the community in finding its own solutions, MWSC attempted to catalyze structural, social, and political changes that empowered the community and, ultimately, individuals within the community, to modify their environment and their behavior to reduce the risk of injury. A community network consisting of 118 members and an external support network of 50 members was established. A social network analysis conducted in 2000 and 2004 indicated that the network doubled its cohesiveness, thereby strengthening its ability to collaborate for mutual benefit. However, while MWSC was rich in social resources, human and financial resources were largely controlled by external agencies. The bridging and linking relationships that connected MWSC to its external support network were the social mechanism MWSC used to access the resources it required to run programs. These boundary-spanning relationships accessed an estimated 6.5 full-time equivalents of human resources and US$750,000 in 2004 that it used to deliver a suite of injury control and safety promotion activities, associated with a 33% reduction in injury deaths over the period 2002 to 2010. MWSC can only be understood in its ecological context. The productivity of MWSC was vulnerable to the changing policy priorities of external sponsoring agents and critically dependent on the advocacy skills of its leaders.

Mackay Whitsunday Safe Communities (MWSC) was developed using a capacity building model that consciously attempted to design sustainability into the network. Our aim was to quantify the flow of resources used by MWSC to implement and sustain its injury control activities. Resource exchange among network members was quantified and analysed using social network analysis. In 2004, MWSC accessed an estimated 6.5 full-time staff equivalents and $0.9 million. However, these resources were largely accessed externally. The linking relationships that connected MWSC to its external support network, more than half of which were maintained by six broker network facilitators, were the critical social asset used to access resources and sustain network productivity. The sustainability of this network and arguably similar safety promotion networks is vulnerable to the changing priorities of external sponsoring agents and highly dependent on its leaders who facilitated access to the resources it required to remain productive.